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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 client has been vomiting for several days. Which blood gas values is he likely to have?
- A. pH=7.32; CO2=60; HCO3=30
- B. pH=7.32; CO2=33; HCO3=18
- C. pH=7.54; CO2=28; HCO3=22
- D. pH=7.54; CO2=32; HCO3=34
Correct Answer: C
Rationale: Prolonged vomiting causes metabolic alkalosis (high pH, low CO2) due to loss of stomach acid, matching pH=7.54, CO2=28, HCO3=22.
The physician has ordered O2 at 3 liters/minute for a client with emphysema. Which device will deliver the most precise level of oxygen prescribed for the client?
- A. Nasal cannula
- B. Partial rebreather mask
- C. Simple face mask
- D. Venturi mask
Correct Answer: D
Rationale: The Venturi mask will deliver the most precise level of oxygen for the client with COPD. Answer A is incorrect, because the client may lose oxygen through an open mouth. Answers B and C are incorrect, because they are not used to deliver oxygen to the client with COPD.
While the nurse is preparing medications, a code occurs. One of the nursing assistants offers to help by administering the medications. What is the best response by the nurse?
- A. Allow the nursing assistant to give the medications
- B. Hold the medications until after the code
- C. Give the medications and then help with the code
- D. Ask the nursing assistant when she was checked off on giving medications
Correct Answer: B
Rationale: Holding medications prioritizes the code response, as CNAs cannot administer medications, ensuring patient safety and appropriate task delegation.
A new mother is two days postpartum, is breastfeeding her infant, and now is preparing for discharge. She states that for contraception she is going to use her diaphragm, which she still has. The nurse's response should be based on which information?
- A. Diaphragms need to be refitted after the birth of a baby.
- B. As long as the diaphragm is in good shape, the client can continue to use it.
- C. Diaphragms are not good contraceptives for postpartal women.
- D. Since the client is breastfeeding, she will not need her diaphragm for four to six months.
Correct Answer: A
Rationale: Postpartum pelvic changes require diaphragm refitting to ensure effective contraception, as size may differ after childbirth.
The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate?
- A. Assign the same nurses and caregivers to the child each day
- B. Avoid mentioning the loved one's death in the child's presence
- C. Explain the importance of being with the child to the parents
- D. Schedule time each day for age-appropriate play
Correct Answer: B
Rationale: Avoiding discussion of the grandparent's death may confuse the child or hinder grieving. Open, age-appropriate communication supports emotional processing.