Nokea
A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, 'I am afraid of needles.' Which of the following actions should the nurse take?
- A. Remind the client that they must receive the medication as prescribed.
- B. Tell the client not to worry because the pain will be temporary.
- C. Request a change in the medication route to PO.
- D. Ask one of the client's loved ones to encourage them to receive the IM medication.
Correct Answer: C
Rationale: Requesting a PO route addresses the client’s fear while ensuring treatment.
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A nurse is reviewing the laboratory results for a client who reports vomiting and diarrhea for 2 days. Which of the following laboratory findings should the nurse expect?
- A. Hypermagnesemia.
- B. Hyperkalemia.
- C. Hyponatremia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, leading to hyponatremia.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Measure the client's BP in the other arm.
- D. Deflate the cuff faster when repeating the BP measurement.
Correct Answer: C
Rationale: Measuring in the other arm confirms accuracy of the elevated reading.
A nurse is assisting in the care of a 72-year-old female client who recently had a stroke and is being monitored for complications. Complete the following sentence by using the lists of options. The client is at risk for developing ___ due to ___.
- A. Deep vein thrombosis (DVT)
- B. Prolonged immobility
- C. Urinary Catheter
- D. constipation
Correct Answer: A,B
Rationale: A: DVT is a risk post-stroke. B: Immobility increases clotting risk.
A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?
- A. Placing the cap of a sterile solution on a clean surface with the inside facing down.
- B. Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field.
- C. Opening the top flap of the sterile tray package away from their body.
- D. Dropping sterile objects onto the field from a height of 5 cm (2 in).
Correct Answer: C
Rationale: Opening the flap away prevents contamination from the nurse’s body.
A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. Encourage your partner to eat three large meals each day.
- B. Opioids will be restricted if your partner develops respiratory distress.
- C. We will use an electric blanket to keep your partner warm.
- D. Assume your partner can hear you, even if they do not respond.
Correct Answer: D
Rationale: Hearing may persist, so speaking provides comfort and connection.