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. Request a change in the medication route to PO.
- B. Remind the client that they must receive the medication as prescribed.
- C. Tell the client not to worry because the pain will be temporary.
- D. Ask one of the client's loved ones to encourage them to receive the IM
Correct Answer: A
Rationale: Requesting a PO route addresses the client's fear while ensuring treatment continuity.
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A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Obtain urine from the drainage bag if a urinary specimen is required.
- B. Use a catheter securing device to hold the catheter in place.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: B
Rationale: A securing device prevents catheter movement and reduces infection risk.
A nurse is caring for a client who has a new prescription for a belt restraint. Which of the following actions should the nurse take?
- A. Make sure four fingers fit between the restraint and the client's body.
- B. Apply the belt restraint over the client's gown.
- C. Check the client's skin integrity every 4 hr.
- D. Tie the belt restraint to the side rail of the bed.
Correct Answer: B
Rationale: Applying over the gown prevents skin irritation and ensures proper fit.
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Provide the client with three large meals eachSigma day.
- B. Limit snacks between meals.
- C. Provide the client with finger foods for meals.
- D. Restrict visitors during meals.
Correct Answer: C
Rationale: Finger foods simplify eating for clients with dementia, increasing intake.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Administer prescribed diuretics in the evening.
- B. Use overhead lighting when checking equipment.
- C. Keep the door to the client's room closed.
- D. Provide the client with snug-fitting nightwear.
Correct Answer: C
Rationale: A closed door reduces noise, promoting sleep.
A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SpO2 level is 88% while on room air. Which of the following actions should the nurse take first?
- A. Recheck the client's SaO2 level after having the client cough and clear their throat.
- B. Notify the charge nurse of the client's condition.
- C. Review the client's most recent SaO2 level in the medical record.
- D. Check the client's medical records to see which medications were recently admitted.
Correct Answer: A
Rationale: Rechecking SpO2 after clearing the airway rules out temporary obstruction as the cause.