Nokea
A nurse is preparing to administer a medication that is available in a glass ampule. Which of the following actions should the nurse plan to take?
- A. The nurse should use a filter needle to withdraw the medication.
- B. The nurse should break the neck of the ampule toward their body.
- C. The nurse should use the same needle to draw up and inject the client.
- D. The nurse should dispose of the ampule in the trash can.
Correct Answer: A
Rationale: The correct answer is A. Using a filter needle to withdraw the medication from a glass ampule helps prevent glass particles from contaminating the medication. Breaking the neck of the ampule toward the body (choice B) can lead to injury. Using the same needle to draw up and inject the client (choice C) increases the risk of contamination. Disposing of the ampule in the trash can (choice D) without following proper disposal protocols can be hazardous.
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A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching?
- A. I know that I can change my advance directives if needed in the future.
- B. My healthcare proxy will make decisions as soon as I sign the power of attorney.
- C. My family can overrule the decisions made by my healthcare proxy.
- D. Advance directives from one state are valid in any other state.
Correct Answer: A
Rationale: Rationale: Option A is correct because it shows the client understands that advance directives can be modified. This is crucial as preferences may change over time. Option B is incorrect as the healthcare proxy only makes decisions when the client cannot. Option C is incorrect as the healthcare proxy's decisions are legally binding. Option D is incorrect because advance directives must comply with state laws and may not be universally recognized.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it sterile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Correct Answer: A
Rationale: The correct answer is A: Remove the cap and place it sterile-side up on a clean surface. This is essential to maintain the sterility of the solution and prevent contamination. Placing the cap sterile-side up ensures that the inside of the cap, which will come in contact with the solution again, remains sterile. Placing it on a clean surface prevents contamination from the surface. Options B, C, and D do not directly address maintaining the sterility of the solution. Option B is about spill management within the sterile field, which is important but not the primary concern when pouring the solution. Holding the bottle in the center (Option C) or with the label facing away (Option D) does not directly impact the sterility of the solution.
A nurse is planning to reposition a client who had a stroke. Which of the following actions should the nurse take?
- A. Evaluate the client's ability to help with repositioning.
- B. Reposition the client without the use of assistive devices.
- C. Raise the side rails on both sides of the client's bed during repositioning.
- D. Discuss the client's preferences for determining a repositioning schedule.
Correct Answer: A
Rationale: The correct answer is A: Evaluate the client's ability to help with repositioning. This is essential as it considers the client's level of participation and promotes independence. Assessing the client's ability to assist ensures safety and prevents injury during repositioning. It also promotes client-centered care by involving the client in their own care.
Choice B is incorrect because repositioning without assistive devices may not be safe or effective, especially for a stroke client who may have limited mobility.
Choice C is incorrect because raising the side rails does not address the client's ability to help with repositioning. It may provide some safety measures but does not actively involve the client in the process.
Choice D is incorrect as discussing preferences for a repositioning schedule does not address the immediate need to evaluate the client's ability to assist with repositioning.
Overall, choice A is the most appropriate as it prioritizes the client's safety, independence, and active participation in their care.
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
- A. Soak feet twice daily.
- B. Round the edges of toenails when trimming.
- C. Use moisturizing lotion between the toes.
- D. Wear clean cotton socks every day.
Correct Answer: D
Rationale: The correct answer is D: Wear clean cotton socks every day. This instruction is essential for proper foot care in diabetes mellitus as it helps prevent fungal infections and keeps feet dry. Soaking feet twice daily (choice A) can lead to skin breakdown. Rounding the edges of toenails (choice B) can increase the risk of ingrown toenails. Using moisturizing lotion between the toes (choice C) can create a moist environment, fostering fungal growth. Therefore, wearing clean cotton socks daily is the most appropriate instruction to promote foot health in a client with diabetes mellitus.
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching?
- A. I will wait 15 minutes after drinking coffee to measure my blood pressure.
- B. I will measure my blood pressure while my arm is elevated above my heart.
- C. I should remove constrictive clothing prior to measuring my blood pressure.
- D. I should measure my blood pressure immediately after eating breakfast.
Correct Answer: C
Rationale: The correct answer is C: "I should remove constrictive clothing prior to measuring my blood pressure." Removing constrictive clothing ensures accurate blood pressure measurement by allowing the cuff to fit properly on the arm without any restrictions, leading to a more reliable reading. Choice A is incorrect as coffee can temporarily increase blood pressure. Choice B is incorrect because the arm should be at heart level, not elevated. Choice D is incorrect as blood pressure should be measured on an empty stomach for accuracy.