Nokea
A nurse is preparing to administer medications to a client. Which of the following pieces of information should the nurse use as a client identifier?
- A. Room number
- B. Medical diagnosis
- C. Photograph
- D. Age
Correct Answer: C
Rationale: A photograph is a reliable identifier per safety standards, unlike room number or age.
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A nurse is assisting with the care of a client who is experiencing dysphagia following a recent stroke. The nurse should initiate a referral to which of the following interprofessional team members?
- A. Speech-language pathologist
- B. Respiratory therapist
- C. Occupational therapist
- D. Registered dietitian
Correct Answer: A
Rationale: A speech-language pathologist specializes in evaluating and treating swallowing difficulties like dysphagia.
A nurse is caring for a client who has insomnia. Which of the following actions should the nurse take?
- A. Administer prescribed diuretics in the evening
- B. Provide the client with snug-fitting nightwear
- C. Keep the door to the client's room closed
- D. Use overhead lighting when checking equipment
Correct Answer: C
Rationale: Closing the door reduces noise, promoting sleep; other options may disrupt it.
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.
A nurse is wearing sterile gloves in preparation for assisting with a client's sterile procedure. While waiting for the procedure to begin, how should the nurse position their hands?
- A. Keep their arms at the sides of their body with their hands in a relaxed position.
- B. Interlock their fingers and hold their hands away from their body above their waist.
- C. Clasp their hands together in a relaxed position behind their body at their waist.
- D. Place one hand over the other against the part of the gown covering their upper body.
Correct Answer: B
Rationale: Interlocking fingers above the waist keeps hands sterile and away from contamination.
A nurse is reinforcing teaching with a group of newly licensed nurses regarding client confidentiality. In which of the following situations can the nurse disclose health information without the client's written consent?
- A. To an insurance agency in regard to a life insurance policy
- B. To an employer for a pre-employment screening
- C. To a medical interpreter service on behalf of a client
- D. To a family member when the client is not available
Correct Answer: C
Rationale: Disclosure to an interpreter is allowed under HIPAA to facilitate care, unlike the other scenarios.