Nokea
A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action?
- A. Assess the condition of the IV site
- B. Check 2 client identifiers before administering medications
- C. Consult a medication guide for compatibility
- D. Wash hands prior to administering medications
Correct Answer: C
Rationale: Ensuring medication compatibility prevents chemical interactions or precipitation in the IV line, which could harm the client or obstruct the catheter.
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The home health nurse is caring for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse determines the client is unresponsive and pulseless, and there are no other caregivers present. Which of the following actions should the nurse take next?
- A. Deliver 30 chest compressions.
- B. Activate the emergency response system.
- C. Locate an automated external defibrillator.
- D. Deliver 2 breaths using a bag valve device connected to the tracheostomy.
Correct Answer: B
Rationale: Activating the emergency response system ensures rapid assistance for a pulseless child, initiating the chain of survival in pediatric cardiac arrest.
The nurse in a long-term care facility observes a nursing assistant caring for a resident who has a hearing aid and dentures. Which action by the nursing assistant should be corrected?
- A. The nursing assistant places a washcloth in the sink before brushing the client's dentures.
- B. The nursing assistant uses toothpaste to clean the dentures.
- C. The nursing assistant uses alcohol to wipe off the exterior of the hearing aid.
- D. The nursing assistant wipes the exterior of the hearing aid with a damp cloth.
Correct Answer: C
Rationale: The exterior of a hearing aid should be wiped regularly with a damp cloth. Alcohol should not be used as it can damage the device. The nursing assistant should place a washcloth in the sink before brushing dentures to protect them if dropped. Toothpaste is appropriate to clean dentures.
A nurse in the pediatric unit is preparing a 16-year-old for a surgical procedure and observes that the client has signed the informed consent for surgery. What should be the first action by the nurse?
- A. Cancel the procedure until a valid consent form is signed
- B. Determine if the client meets legal requirements to sign the consent form
- C. Locate the client's parent or guardian to sign the consent form
- D. Verify that the consent is properly witnessed and send the client to surgery
Correct Answer: B
Rationale: Minors typically cannot provide legal consent unless they are emancipated or meet specific legal criteria. The nurse must first determine if the 16-year-old is legally able to sign the consent.
A client with severe hypertension is receiving Capoten (captopril). The nurse should instruct the client to report which of the following to the doctor?
- A. Coughing
- B. Drowsiness
- C. Frequent urination
- D. Hunger
Correct Answer: A
Rationale: A persistent cough is a common side effect of ACE inhibitors like captopril, potentially requiring a change in medication.
A 20-year-old woman is admitted to the hospital following an accident. Her uncle, a physician from out of state, visits her and asks to see her chart. How should the nurse respond?
- A. Comply with the request and give the chart to the physician
- B. Explain that written permission from his niece is needed first
- C. Suggest that he discuss the case with the attending physician
- D. Give him the chart but do not let him remove it from the nurse's station
Correct Answer: B
Rationale: HIPAA regulations require patient consent for chart access, even by a physician relative, unless they are directly involved in care. Permission from the patient is needed first.