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A nurse is reviewing error prevention techniques that would have helped to avoid a medication error. Which technique is most effective?
- A. Double check all dosage calculations.
- B. nusually large or small doses.
- C. Compare the medication label to the order.
- D. Use at least 2 client identifiers before administering a dose.
- E. Involve and educate clients in medication administration.
Correct Answer: D
Rationale: Identifiers prevent misidentification.
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The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
- A. Record a palpable systolic pressure of 90 mm Hg.
- B. Release the manometer valve immediately.
- C. Document the absence of the radial pulse.
- D. Inflate the blood pressure cuff to 120 mm Hg.
Correct Answer: D
Rationale: Inflate above pulse disappearance for accuracy.
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
- A. Verify placement of pulse oximeter.
- B. Increase the oxygen to 3 L/minute.
- C. Remove nasal cannula.
- D. Switch to a non-rebreather mask.
Correct Answer: A
Rationale: Verifying placement ensures accurate readings.
The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?
- A. Offering therapeutic support to a grieving family.
- B. Obtaining clarification from a client’s healthcare power-of-attorney.
- C. Reporting a change in a client’s condition to the healthcare provider.
- D. Completing discharge teaching to a client and family members.
Correct Answer: C
Rationale: SBAR is for clinical communication.
A family requested a visit from a hospice nurse as they think the client appears to be nearing the end of life. The nurse assesses the client. Which of the following signs indicate that the client is near death?
- A. Decreased muscle tone, relaxed jaw muscles, sagging mouth.
- B. Urine output is clear yellow.
- C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern).
- D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).
Correct Answer: A,C,D
Rationale: Muscle tone, breathing, and secretions indicate nearing death.
When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
- A. Assess strength of deep tendon reflexes.
- B. Determine apical pulse rate and rhythm.
- C. Observe color and amount of urine.
- D. Compare muscle strength bilaterally.
Correct Answer: B
Rationale: Hyperkalemia risks arrhythmias; cardiac monitoring is critical.