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A nurse is working with a newly hired nurse who is administering meds to clients. Which of the following actions by the newly hired nurse indicates an understanding of med error prevention?
- A. Taking all meds out of the unit-dose wrappers before entering the client's room.
- B. Checking with the provider when a single dose requires administration of multiple tablets.
- C. Administering a med, then looking up the usual dosage range.
- D. Relying on another nurse to clarify a med prescription.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Choice B demonstrates understanding of med error prevention because checking with the provider when a single dose requires administration of multiple tablets ensures accuracy in medication administration. This step helps prevent medication errors related to dosage calculation and administration. By consulting the provider, the nurse confirms the correct dosage and avoids potential overdosing or underdosing, which are common causes of medication errors. This action aligns with the principles of safe medication administration and prioritizes patient safety.
Incorrect Choices:
A: Taking all meds out of the unit-dose wrappers before entering the client's room can lead to medication mix-ups and errors, as it increases the risk of confusion and misidentification of medications.
C: Administering a med, then looking up the usual dosage range is risky as it may result in incorrect dosing and jeopardize patient safety.
D: Relying on another nurse to clarify a med prescription is problematic as it bypasses the responsibility of verifying medication orders directly with the prescriber
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A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents.'
- B. It's been so stressful for me to even think about having my own family.'
- C. I don't even know who I am yet, & now I'm supposed to know what to do.'
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father.'
Correct Answer: C
Rationale: The correct answer is C: "I don't even know who I am yet, & now I'm supposed to know what to do." This statement highlights an existential crisis and identity confusion, which are common developmental challenges in young adulthood. It indicates a lack of self-awareness and direction, which can significantly impact the individual's overall well-being and decision-making capabilities. Addressing this issue is crucial as it forms the foundation for addressing other concerns effectively. Choices A, B, and D focus on external stressors and specific situations, which are important but secondary to the core issue of self-identity. Therefore, prioritizing assessment and intervention for the client's self-identity crisis is essential to promote holistic growth and resolution of other challenges.
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Select all.
- A. Keep the head of the bed elevated 30 degrees
- B. Massage the client's bony prominences often
- C. Apply cornstarch liberally to the skin after bathing
- D. Have the client sit on a gel cushion when in a chair
- E. Reposition the client at least Q 3 hr while in bed
Correct Answer: A, D
Rationale: The correct interventions (A and D) are crucial for preventing pressure ulcers in older adults. Elevating the head of the bed at 30 degrees helps reduce pressure on the sacrum and heels, key areas prone to pressure ulcers. Sitting on a gel cushion distributes pressure evenly, reducing the risk of skin breakdown.
Incorrect Choices:
B: Massaging bony prominences can increase friction and shear forces, leading to skin breakdown.
C: Cornstarch can create a moist environment, increasing the risk of maceration and skin breakdown.
E: Repositioning every 3 hours is insufficient for preventing pressure ulcers, as more frequent repositioning is needed to reduce prolonged pressure on the skin.
A nurse is instructing a postop client about the sequential compression device the provider has prescribed. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. This device will keep me from getting sores on my skin.
- B. This thing will keep the blood pumping through my leg.
- C. With this thing on, my leg muscles won't get weak.
- D. This device is going to keep my joints in good shape.
Correct Answer: B
Rationale: The correct answer is B: "This thing will keep the blood pumping through my leg." This statement shows understanding because sequential compression devices help prevent blood clots by promoting blood circulation in the legs. Option A is incorrect as the device does not prevent skin sores. Option C is incorrect as it doesn't specifically address blood circulation. Option D is incorrect as the device does not impact joint health.
A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk medication for the control of seizures. Which of the following statements by the nurse is appropriate?
- A. This medication is prescribed if necessary but is known to cause adverse effects to the fetus.
- B. This medication has evidence indicating that it is safe to take during pregnancy and will not harm the fetus.
- C. This medication cannot be taken during pregnancy because the risk outweighs the potential benefits.
- D. This medication hasn't been studied in pregnant women but is believed to be safe for the fetus.
Correct Answer: A
Rationale: The correct answer is A. Category D medications have shown evidence of risk to the fetus in human studies but potential benefits may outweigh risks in certain situations. The nurse should inform the client about the risks and benefits of continuing the medication while trying to conceive. Choice B is incorrect because Category D medications are not considered safe during pregnancy. Choice C is incorrect as it is not entirely true that the risk always outweighs the benefits. Choice D is incorrect because assuming safety without evidence is risky. The nurse should provide accurate information to guide the client's decision-making.
A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all.
- A. Most food poisoning is caused by a virus
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products
- D. Healthy individuals usually recover from the illness in a few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B, C, E
Rationale: The correct choices are B, C, and E. B is correct because immunocompromised individuals have weakened immune systems, making them more susceptible to severe complications from food poisoning. C is correct because pasteurized dairy products are less likely to contain harmful bacteria that can cause food poisoning. E is correct because proper food handling, such as separating raw and fresh foods to prevent cross-contamination, can help reduce the risk of food poisoning. A is incorrect because most food poisoning is actually caused by bacteria, not viruses. D is incorrect because while healthy individuals may recover from food poisoning, the recovery time can vary and may not always be within a few weeks.