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A nurse is assisting with a community health presentation about home safety precautions when there is an outdoor chemical disaster nearby. Which of the following instructions should the nurse include?
- A. Exit the home as quickly as possible.
- B. Turn on ceiling fans and air conditioners.
- C. Cover heat registers with plastic and tape.
- D. Open the dampers of fireplaces.
Correct Answer: C
Rationale: Covering heat registers prevents chemical entry indoors.
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A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN). Which of the following actions should the nurse take?
- A. Place the client in Sims' position for catheter insertion.
- B. Verify the amount of TPN solution the client is receiving every 4 hr.
- C. Use clean technique when changing the catheter dressing.
- D. Prepare the client for a chest x-ray to verify catheter placement.
Correct Answer: D
Rationale: A chest x-ray confirms correct catheter placement for TPN administration.
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Offer the client several choices at mealtimes.
- B. Alternate daily caregivers.
- C. Avoid discussing the client's fears.
- D. Remind the client of the day and time often.
Correct Answer: D
Rationale: Frequent orientation to time reduces confusion in delirium.
A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply)
- A. Instruct another nurse to record the prescription in the medical record.
- B. Ask the provider to spell out the name of the medication.
- C. Withhold the medication until the provider signs the prescription.
- D. Record the date and time of the telephone prescription.
- E. Request that the provider confirm the read-back of the prescription.
Correct Answer: B,D,E
Rationale: Spelling the medication, recording date/time, and confirming read-back ensure accuracy and safety.
A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?
- A. Evaluate the need for the client to remain in mitten restraints.
- B. Determine the circulation status of the affected extremities every 2 hr.
- C. Instruct the client's family about the purpose of mitten restraints.
- D. Assist the client with range-of-motion exercises of the hands.
Correct Answer: D
Rationale: Assisting with range-of-motion is within the AP's scope, unlike evaluation or teaching.
The client has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin.
A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?
- A. You will suffer serious health issues if you don't take your medication.
- B. Have you considered how your decision to refuse medication will affect your family?
- C. I'd like to hear your thoughts about giving yourself this medication.
- D. Why don't you want to learn how to give yourself your medication?
Correct Answer: C
Rationale: Exploring the client's thoughts promotes understanding and respects autonomy.