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A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. After education, the client refuses to take the medication. Which of the following actions should the nurse take?
- A. Notify the facility’s ethics committee
- B. Return the opened medication to the medication cart
- C. Report the incident to the provider
- D. Fill out an incident report
Correct Answer: C
Rationale: The correct answer is C: Report the incident to the provider. The nurse should report the client's refusal to take the medication to the provider to ensure appropriate documentation and follow-up care. This step is crucial for the client's safety and well-being.
A: Notifying the ethics committee is not necessary in this situation as the provider should be the first point of contact.
B: Returning the opened medication to the cart is inappropriate and unsafe as it could lead to medication errors.
D: Filling out an incident report may be necessary, but reporting to the provider should be the immediate action.
In summary, option C is the correct choice as it prioritizes the client's care and ensures proper communication with the healthcare provider.
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A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.
A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?
- A. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading
- B. Place the sensor probe on the same extremity as an electronic blood pressure cuff
- C. Relocate the sensor every 8 hrs
- D. Choose a finger with a capillary refill less than 2 sec
Correct Answer: D
Rationale: The correct answer is D: Choose a finger with a capillary refill less than 2 sec. This is important because a capillary refill time longer than 2 seconds may indicate poor circulation, which can affect the accuracy of the oxygen saturation reading. It ensures proper blood flow to the finger, leading to a more reliable measurement. Waiting 10 seconds before obtaining the reading (A) is unnecessary and may delay timely intervention. Placing the sensor probe on the same extremity as an electronic blood pressure cuff (B) can interfere with accurate readings. Relocating the sensor every 8 hours (C) is not necessary for routine monitoring and may disrupt continuous monitoring.
A nurse is caring for a client with a scheduled procedure. While preparing the client for transport they appear anxious and ask the nurse where they should hide their cellphone during the procedure. The nurse offers to lock the item in a secure area. Which category of Maslow's hierarchy of needs is the nurse addressing?
- A. Safety needs
- B. Esteem needs
- C. Love and belonging needs
- D. Physiological needs
Correct Answer: A
Rationale: The correct answer is A: Safety needs. At this moment, the nurse is addressing the client's need for safety by offering to secure their cellphone. Safety needs in Maslow's hierarchy refer to feeling secure, stable, and protected. By ensuring the client's belongings are safe, the nurse is addressing this fundamental need, which is crucial for the client's well-being during the procedure. Other choices are incorrect because: B: Esteem needs focus on self-respect and recognition from others, C: Love and belonging needs refer to relationships and social connections, and D: Physiological needs pertain to basic requirements like food and water, none of which are directly addressed in this scenario.
A nurse is teaching a client who has a new prescription for zolpidem. The nurse should instruct the client that which of the following is an adverse effect of zolpidem?
- A. Memory loss
- B. Dry mouth
- C. Hypertension
- D. Urinary retention
Correct Answer: A
Rationale: The correct answer is A: Memory loss. Zolpidem is a sedative-hypnotic medication commonly used for insomnia. One of its adverse effects is memory loss, particularly short-term memory impairment. Zolpidem works by enhancing the effects of GABA, which can lead to memory issues. Dry mouth (B) is a common side effect of many medications but not typically associated with zolpidem. Hypertension (C) and urinary retention (D) are not common adverse effects of zolpidem. It is important to educate the client about memory loss as a potential side effect to ensure they are aware and can report any concerning symptoms to their healthcare provider.
A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Holds their hands below elbows while rinsing off soap
- B. Uses hot water to wash their hands
- C. Turns off the faucet with their hands
- D. Washes their hands for 10 seconds
Correct Answer: A
Rationale: The correct answer is A because holding hands below elbows while rinsing off soap prevents contamination of clean hands by dirty water. This action ensures proper hand hygiene by maintaining a unidirectional flow of water from clean to dirty areas. Choice B using hot water is incorrect as it may cause skin irritation. Choice C turning off the faucet with hands can reintroduce contamination. Choice D washing hands for only 10 seconds is insufficient for effective hand hygiene.