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A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)
- A. A client reports being dissatisfied with the temperature of the meals provided.
- B. A client receives burns from a heating pad.
- C. A client becomes disoriented and falls out of bed.
- D. A client is unable to afford the physical therapy that the provider recommends.
- E. A client's visitor becomes dizzy and faints in the client's room.
Correct Answer: B,C,E
Rationale: B: Burns indicate harm. C: Falls require reporting. E: Visitor fainting is an unexpected event.
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A nurse is collecting data from a client who reports an inability to cope because of their recent job loss. Which of the following actions should the nurse take?
- A. Tell the client to think about something else.
- B. Ask the client to describe their support system.
- C. Ask the client why they're unable to cope.
- D. Tell the client that everything will be okay.
Correct Answer: B
Rationale: Assessing the support system identifies resources to help the client cope.
A nurse is contributing to a community center's in-service program about early detection of breast cancer. Which of the following recommendations should the nurse make for female clients who do not have a family history of breast cancer?
- A. You should receive a breast examination from your provider each year after age 30.
- B. You should start receiving mammograms as early as age 40.
- C. You should receive a breast ultrasound every 3 years after age 50.
- D. You should start performing monthly breast self-examinations at age 35.
Correct Answer: A
Rationale: Annual clinical breast exams are recommended starting at age 30 for early detection.
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?
- A. Add 0.5 mL of diluent to the medication.
- B. Inject air into the ampule prior to drawing the medication into a syringe.
- C. Use a filter needle to aspirate the medication.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: C
Rationale: A filter needle prevents glass particles from being drawn into the syringe from the ampule.
A nurse is providing end-of-life care to a client who is experiencing dyspnea. Which of the following actions should the nurse take?
- A. Provide oral care to the client once every 8 hr.
- B. Reposition the client once every 4 hr.
- C. Place the head of the client's bed flat.
- D. Use a fan to circulate air in the client's room.
Correct Answer: B
Rationale: Repositioning helps relieve dyspnea by improving lung expansion and comfort.
Nurses' Notes
Vital Signs
Diagnostic Results
6 months ago:
Client present today for annual examination. Reports lack of sleep and increased stress due to moving and starting a new job.
Today, 1400:
Client presents to office today with reports of fatigue. Client states they have difficulty sleeping without drinking four or five beers a night. Client reports, "I sometimes get headaches along with nausea and vomiting. I have been busy with my new job, so I have been eating a lot of fast food, and I've gained 15 pounds."
Today, 1445.
Provider notified of laboratory results.
A nurse is assisting in the care of a client in a provider's office. A nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Administer a diuretic.
- B. Limit alcohol intake to 2 drinks per day.
- C. Keep daily fat intake to less than 35%
- D. Place on 2300 mg sodium diet.
- E. Administer an antibiotic
- F. Limit foods high in potassium.
Correct Answer: A, B, C, D
Rationale: A: Addresses fluid retention from fast food. B, C, D: Manage weight gain and hypertension risks.