Nokea
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. Inject air into the ampule prior to drawing the medication into a syringe.
- B. Add 0.5 mL of diluent to the medication.
- 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: Using a filter needle ensures no glass contaminants are administered.
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A nurse is reinforcing teaching about end-of-life care with the partner of a client. Which of the following statements should the nurse make?
- A. Encourage your partner to eat three large meals each day.
- B. Opioids will be restricted if your partner develops respiratory distress.
- C. We will use an electric blanket to keep your partner warm.
- D. Assume your partner can hear you, even if they do not respond.
Correct Answer: D
Rationale: Hearing may persist, so speaking provides comfort and connection.
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
- A. Pad bony prominences before applying a restraint.
- B. Tie the ends of the restraint to the client's bed rail.
- C. Use a square knot to secure the client's restraint to the bed.
- D. Observe the client's skin integrity every 2 hr.
- E. Ensure that 2 fingers can be placed between the restraint and the client.
Correct Answer: A,D,E
Rationale: A: Prevents skin breakdown. D: Ensures early detection of issues. E: Ensures proper fit and circulation.
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Using a quick-release tie to secure the restraint.
- B. Tying the restraint to the bed frame.
- C. Placing the restraint across the client's chest.
- D. Applying the restraint over the client's gown.
Correct Answer: C
Rationale: Placing the restraint across the chest restricts breathing and is unsafe, requiring intervention.
A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'm glad to have the opportunity to choose what kind of care I receive while I still can.
- B. I can't change my mind about the care I will receive once I sign my living will.
- C. Once I fill out my living will, there will be a 1-month delay before it is legally binding.
- D. If I want life support, I'll need to sign a separate consent form first.
Correct Answer: A
Rationale: This reflects understanding that advance directives allow care choices while capable.
A nurse is caring for a 65-year-old male client in the emergency department. The client is presenting with symptoms of a potential cardiac event and has been admitted for further evaluation. Complete the following sentence by selecting the most appropriate actions based on the client’s current status. The nurse should first ___ then ___.
- A. Notify the primary health care provider immediately.
- B. Start an IV line for potential medication administration.
- C. move patient to ICU
Correct Answer: A,B
Rationale: A: Notifying the provider addresses potential cardiac event urgency. B: IV line ensures rapid medication access.