A nurse is caring for a client who is receiving IV fluids. Which of the following actions should the nurse take to prevent infection?
- A. Change the IV tubing every 24 hr.
- B. Clean the IV insertion site with alcohol before insertion.
- C. Monitor the IV site for redness or swelling.
- D. Use a new IV catheter for each attempt.
Correct Answer: C
Rationale: Monitoring for redness or swelling detects infection early. Tubing changes are every 72-96 hours, alcohol is standard, and new catheters are used per attempt.
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A nurse is reinforcing teaching with a client who has a new prescription for gabapentin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication with a high-fat meal.
- B. I might feel sleepy while taking this medication.
- C. I need to avoid sunlight while taking this medication.
- D. I can stop taking this medication as soon as my pain goes away.
Correct Answer: B
Rationale: Gabapentin can cause drowsiness, reflecting understanding. Food intake is flexible, sunlight isn't a concern, and stopping needs tapering.
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. Justice
- B. Autonomy
- C. Veracity
- D. Beneficence
Correct Answer: C
Rationale: Veracity involves truthful communication. By honestly discussing medication side effects, the nurse upholds this principle, supporting informed decision-making.
A nurse is reinforcing teaching with a client who has a new prescription for losartan. Which of the following statements should the nurse include?
- A. You should take this medication with a high-potassium meal.
- B. You might experience dizziness while taking this medication.
- C. You need to limit your exercise while taking this medication.
- D. You can take this medication at any time of day.
Correct Answer: B
Rationale: Losartan can cause dizziness due to blood pressure lowering, a key safety concern. Potassium meals, exercise limits, or flexible timing aren't primary considerations.
A nurse is caring for a client who is receiving continuous enteral feeding. Which of the following actions should the nurse take?
- A. Check gastric residual volume every 4 hr.
- B. Flush the tube with water every 12 hr.
- C. Position the client supine during feeding.
- D. Change the feeding bag every 48 hr.
Correct Answer: A
Rationale: Checking residual volume every 4 hours assesses tolerance, preventing aspiration. Flushing is more frequent, supine positioning risks aspiration, and bags change every 24 hours.
A nurse in a provider's office is caring for a group of clients who have communicable diseases. Which of the following infections should the nurse report to the state health department?
- A. Human papillomavirus
- B. Neisseria gonorrhoeae
- C. Impetigo contagious
- D. Sarcoptes scabiei
Correct Answer: B
Rationale: Neisseria gonorrhoeae is a reportable sexually transmitted infection to track and control its spread. HPV, impetigo, and scabies are not typically reportable to state health departments.
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