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. Add 0.5 mL of diluent to the medication.
- B. Use a filter needle to aspirate the medication.
- C. Inject air into the ampule prior to drawing the medication into a syringe.
- D. Cleanse the tip of the ampule with an alcohol swab after opening.
Correct Answer: B
Rationale: A filter needle prevents glass particles from being drawn into the syringe from the ampule.
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A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I can name my sibling as my designee in my durable power of attorney for health care.
- B. I need to create advance directives so that I can donate my organs.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: A
Rationale: Naming a sibling as a designee is a correct use of a durable power of attorney for health care.
A charge nurse on a long-term care unit is working with an assistive personnel who states, 'I am tired of all the changes on this unit. If things don't improve soon, I'm requesting a transfer.' Which of the following responses should the charge nurse make?
- A. Why don't you just file a formal complaint with Human Resources?
- B. Please, try to wait a little longer. Things will get better soon.
- C. There has been too much complaining about these changes.
- D. So, you are upset about all of the recent changes on the unit?
Correct Answer: D
Rationale: Reflecting the AP's feelings fosters communication and addresses concerns constructively.
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. Reposition the client once every 4 hr.
- B. Provide oral care to the client once every 8 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: D
Rationale: A fan improves air movement, easing dyspnea in end-of-life care.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will move the cane forward 18 inches.
- B. I will hold the cane on my stronger side.
- C. I should wear shoes with smooth soles to help slide my weak leg forward.
- D. I should move my stronger leg forward before moving my weaker leg.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support and balance for the weaker side.
A nurse at a long-term care facility is caring for an older adult client who has dementia and is at risk for malnutrition. Which of the following actions should the nurse take to promote an increase in food intake?
- A. Limit snacks between meals.
- B. Restrict visitors during meals.
- C. Provide the client with three large meals each day.
- D. Provide the client with finger foods for meals.
Correct Answer: D
Rationale: Finger foods are easier for dementia clients to manage, encouraging self-feeding and intake.