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. Age
- D. Photograph
Correct Answer: D
Rationale: A photograph provides a unique, visual confirmation of identity for safe medication administration.
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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 a family member when the client is not available
- B. To an employer for a pre-employment screening
- C. To an insurance agency in regard to a life insurance policy
- D. To a medical interpreter service on behalf of a client
Correct Answer: D
Rationale: Disclosure to an interpreter facilitates care and is permitted under HIPAA without consent.
0800:
The client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs stopped. Client is confused and lethargic. Bilateral breath sounds clear. Oxygen applied 3 L/min via nasal cannula. Oxygen saturation 95%.
At 1000 the nurse enters the client's room. The first action the nurse should take is followed by
- A. Remove the pillows
- B. Turn the client to their side
- C. call for emergency assistance
- E. initiate IV fluids
- F. document seizure
- G. prepare medications
Correct Answer: A,B
Rationale: Removing pillows prevents airway obstruction; turning to the side aids drainage during a seizure.
A nurse is preparing to reinforce teaching with a client who has expressive aphasia. Which of the following actions should the nurse plan to take?
- A. Provide the teaching without expecting the client to respond.
- B. Speak with a loud voice while providing the information.
- C. Avoid the use of facial gestures during the instructions.
- D. Determine the client's ability to use a communication board.
Correct Answer: D
Rationale: A communication board aids expression in expressive aphasia, enhancing understanding.
A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.
- A. Prepare a dry work surface above the waist level.
- B. Open the outside cover of the sterile kit and remove the dust cover.
- C. Grasp the outermost flap of the sterile kit while opening away from the body.
- D. Open each side flap of the sterile kit individually while pulling to the side.
- E. Open the innermost lower flap of the sterile kit while standing away from the sterile field.
Correct Answer: A,B,C,D,E
Rationale: This sequence (A,B,C,D,E) maintains sterility by preparing, opening away, and avoiding contamination.
A nurse is preparing to administer ampicillin to a school-age child who weighs 55 lb. The provider prescribes 50 mg/kg/day in 4 equal doses. Available is ampicillin oral suspension 125 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 12.5 mL
Rationale: 55 lb = 25 kg; 25 kg × 50 mg/kg/day = 1250 mg/day; 1250 mg ÷ 4 = 312.5 mg/dose; 312.5 mg ÷ (125 mg/5 mL) = 12.5 mL.