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A nurse is assessing a client who is reporting severe pain despite analgesia. The nurse can best assess the intensity of the client's pain by:
- A. Asking what precipitates the pain
- B. Questioning the client about the location of the pain
- C. Offering the client a pain scale to measure his pain
- D. Using open-ended questions to identify the situation
Correct Answer: C
Rationale: The correct answer is C: Offering the client a pain scale to measure his pain. This is the best way to assess the intensity of the client's pain objectively. Pain scales provide a standardized way for clients to communicate their pain levels, allowing for more accurate assessment and monitoring. Asking what precipitates the pain (choice A) focuses on triggers, not intensity. Questioning about the location of pain (choice B) is important but doesn't directly measure intensity. Using open-ended questions (choice D) may not provide a quantitative measure of pain.
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A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
- A. Remind the nurse that safe client care is a priority on the unit
- B. Ask others on the team whether they have observed the same behavior
- C. Report observations to the nurse manager on the unit
- D. Conclude that her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.
A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all.
- A. I will observe for med side effects.
- B. I will monitor for therapeutic effects.
- C. I will prescribe the appropriate dose.
- D. I will change the dose if adverse effects occur.
- E. I will refuse to give a med if I believe it is unsafe.
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A nurse's responsibility in implementing medication therapy includes observing for side effects (A), monitoring for therapeutic effects (B), and refusing to give a medication if they believe it is unsafe (E).
A - Observing for side effects is crucial in ensuring patient safety and prompt intervention if adverse reactions occur.
B - Monitoring for therapeutic effects helps assess the effectiveness of the medication in achieving the desired outcomes for the patient's condition.
E - Refusing to give a medication if the nurse believes it is unsafe demonstrates advocacy for the patient's well-being and adherence to the principles of safe medication administration.
Choices C and D are incorrect because nurses should not prescribe or change medication doses without proper authorization from a prescribing healthcare provider. It is beyond the scope of a nurse's role.
In summary, the correct answers focus on patient safety, monitoring effectiveness, and advocating for the patient's best interest, while the incorrect choices involve actions outside the nurse's scope
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
- A. Check how long the feeding container has been opened.
- B. Verify the placement of the NG tube.
- C. Confirm that the client doesn't have diarrhea.
- D. Make sure the client is alert & oriented.
Correct Answer: B
Rationale: The correct answer is B: Verify the placement of the NG tube. This is the highest assessment priority before instilling enteral feeding to prevent complications like aspiration. The nurse must ensure the NG tube is correctly positioned in the stomach to avoid feeding into the lungs. Checking the length of time the feeding container has been open (A) is important but not as critical as verifying tube placement. Confirming the client doesn't have diarrhea (C) is important for monitoring overall health but not directly related to the procedure. Ensuring the client is alert and oriented (D) is essential but not the priority for this specific procedure.
A nurse is teaching a client about taking multiple oral meds at home to include time-release capsules, liquid meds, enteric-coated pills, & narcotics. Which of the following statements by the client indicates an understanding of the teaching?
- A. I can open the capsule w/the beads in it & sprinkle them on my oatmeal.
- B. If I am having difficulty swallowing, I will add the liquid meds to a batch of pudding.
- C. The pills w/the coating on them can be crushed.
- D. I will eat 2 crackers w/the pain pills.
Correct Answer: D
Rationale: The correct answer is D: "I will eat 2 crackers with the pain pills." This statement indicates an understanding of the teaching because taking narcotics with food, such as crackers, can help reduce stomach upset and nausea commonly associated with these medications. This demonstrates the client's awareness of the importance of food intake when taking certain medications.
Choice A is incorrect because opening a time-release capsule and sprinkling the beads on food can alter the medication's intended release mechanism. Choice B is incorrect as mixing liquid meds with pudding may not ensure proper dosage or absorption. Choice C is incorrect as crushing enteric-coated pills can interfere with their delayed-release properties.
A nurse is working with a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention?
- A. Taking all meds out of the unit-dose wrappers before entering the client's room.
- B. Checking with the provider when a single dose requires administration of multiple tablets.
- C. Administering a med, then looking up the usual dosage range.
- D. Relying on another nurse to clarify a med prescription.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Choice B demonstrates understanding of med error prevention because checking with the provider when a single dose requires administration of multiple tablets ensures accuracy in medication administration. This step helps prevent medication errors related to dosage calculation and administration. By consulting the provider, the nurse confirms the correct dosage and avoids potential overdosing or underdosing, which are common causes of medication errors. This action aligns with the principles of safe medication administration and prioritizes patient safety.
Incorrect Choices:
A: Taking all meds out of the unit-dose wrappers before entering the client's room can lead to medication mix-ups and errors, as it increases the risk of confusion and misidentification of medications.
C: Administering a med, then looking up the usual dosage range is risky as it may result in incorrect dosing and jeopardize patient safety.
D: Relying on another nurse to clarify a med prescription is problematic as it bypasses the responsibility of verifying medication orders directly with the prescriber