Nokea
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage.
- B. Notify the pharmacy when wasting the medication.
- C. Lock the remaining medication in the controlled substances cabinet.
- D. Dispose of the vial with the remaining medication in a sharps container.
Correct Answer: C
Rationale: The correct answer is C: Lock the remaining medication in the controlled substances cabinet. This is the correct action because opioids are controlled substances that require strict security measures to prevent diversion or misuse. By locking the remaining medication in the controlled substances cabinet, the nurse ensures that it is securely stored and accounted for.
Choice A: Asking another nurse to observe the medication wastage is unnecessary in this situation as the remaining medication should be properly secured rather than observed.
Choice B: Notifying the pharmacy when wasting the medication may be required for documentation purposes, but it does not address the immediate need to secure the remaining medication.
Choice D: Disposing of the vial with the remaining medication in a sharps container is incorrect as it does not follow proper protocol for handling controlled substances.
In summary, choice C is the correct action as it aligns with the necessary security measures for handling opioids, while the other choices do not address the specific requirements for controlled substances.
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A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 107
Rationale: To calculate the infusion rate, divide the total volume (750 mL) by the total time in hours (7 hr). This gives 107.14 mL/hr, rounded to 107 mL/hr. This ensures the correct administration of the solution over the specified time. Other choices are incorrect as they do not result from the correct calculation method, leading to incorrect infusion rates and potentially affecting patient outcomes.
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
- A. Combine client care tasks when caring for multiple clients.
- B. Wait until the end of the shift to document client care.
- C. Use the planning step of the nursing process to prioritize client care delivery.
- D. Allow for interruptions in tasks to discuss client care issues with colleagues.
Correct Answer: C
Rationale: Correct Answer: C - Use the planning step of the nursing process to prioritize client care delivery.
Rationale:
1. The planning step involves setting goals, outcomes, and interventions, helping the nurse organize and prioritize care efficiently.
2. Prioritizing care based on client needs ensures critical tasks are addressed first, promoting client safety and well-being.
3. It allows the nurse to allocate time effectively, focusing on urgent and important tasks first.
4. By following the nursing process, the nurse can provide individualized care tailored to each client's specific needs.
Incorrect Choices:
A: Combining tasks can lead to overlooking important details for each client.
B: Waiting to document care can result in errors, omissions, and delays in communication.
D: Allowing interruptions can disrupt workflow and hinder efficient time management.
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
- A. Document the provider's statement in the medical record.
- B. Consult the facility's risk manager.
- C. Complete an incident report.
- D. Notify the nursing manager.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should document the provider's statement in the medical record. This is important for legal and communication purposes. By documenting the surgeon's instructions, the nurse ensures that the care provided is well-documented and can be tracked for continuity of care. It also serves as evidence that the nurse followed the provider's orders appropriately.
Summary:
B: Consulting the facility's risk manager is not necessary at this point as the situation does not involve a risk management issue.
C: Completing an incident report is not warranted as there is no indication of an incident or error that has occurred.
D: Notifying the nursing manager is not the immediate action required in this situation. The nurse should prioritize following the provider's instructions and documenting the communication.
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply)
- A. Lacrimal apparatus
- B. Pupil clarity
- C. Appearance of bulbar conjunctivae
- D. Visual fields
- E. Visual acuity
Correct Answer: D,E
Rationale: The correct assessments for identifying an older adult client's safety needs are visual fields (D) and visual acuity (E). Visual fields evaluate peripheral vision, important for detecting obstacles and hazards. Impaired visual acuity can affect depth perception and balance, increasing fall risk. Lacrimal apparatus (A) assesses tear production, not directly related to fall risk. Pupil clarity (B) and appearance of bulbar conjunctivae (C) are more related to eye health but do not directly assess fall risk in older adults.
A nurse is talking with an older adult client who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. You would have so much more time to spend with your family.'
- B. You should consider getting a part-time job or doing volunteer work.'
- C. Let's talk about how the change in your job status will affect you.'
- D. Why wouldn't you want to retire and relax?
Correct Answer: C
Rationale: The correct response is C: "Let's talk about how the change in your job status will affect you." This response shows empathy and understanding towards the client's concerns and opens up a dialogue to explore the client's feelings and thoughts about retirement. It allows the nurse to assess the client's emotional readiness and concerns, facilitating a supportive conversation.
Other choices are incorrect:
A: This response assumes that the client's main concern is spending time with family, which may not be the case.
B: While volunteering or working part-time are valid options, this response does not address the client's current feelings and may come across as dismissive.
D: This response is judgmental and does not acknowledge the client's perspective or concerns, potentially shutting down communication.