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While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications.
A nurse is caring for a client who has been admitted to the mental health unit. While reinforcing teaching about the client's prescribed medications, the nurse communicates truthfully about the adverse effects of the medications. Which of the following ethical concepts is the nurse exhibiting?
- A. Autonomy
- B. Justice
- C. Veracity
- D. Beneficence
Correct Answer: C
Rationale: Veracity reflects truthfulness, as the nurse honestly discusses medication adverse effects.
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A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?
- A. Inject 15 units of air into the regular insulin vial.
- B. Withdraw 10 units of NPH insulin.
- C. Verify the dosage with another nurse.
- D. Place the cap over the needle.
Correct Answer: A
Rationale: Injecting air into the regular insulin vial next follows the correct sequence for mixing insulins.
The client has methicillin-resistant Staphylococcus aureus (MRSA).
A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
- A. Don gloves prior to assisting the client with brushing their teeth.
- B. Have the client wear a mask when they are out of their room.
- C. Ensure that the negative air pressure is active for the client's room.
- D. Place the client in a room with a high-efficiency particulate air (HEPA) filter.
Correct Answer: A
Rationale: Gloves prevent MRSA transmission during close contact like brushing teeth.
The client is visibly agitated and talking loudly in a group therapy session.
A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?
- A. Place the client in seclusion.
- B. Assist the client with understanding their needs.
- C. Ask the client to identify what made them upset.
- D. Administer lorazepam IM.
Correct Answer: C
Rationale: Identifying the trigger de-escalates agitation before further intervention.
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
- A. Decreased blood pressure
- B. Decreased skin turgor
- C. Weight loss
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate fluid overload from excessive enteral feeding.
A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
- A. Monitor the client for 1 hr after meals.
- B. Weigh the client every 2 days.
- C. Check the client's vital signs two times per week.
- D. Allow the client 2 hr to finish meals.
Correct Answer: A
Rationale: Monitoring for 1 hour after meals prevents purging, a key intervention for anorexia.