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After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.At checking the restraints, which action is most important for the nurse to take?
- A. Reinsert the peripheral IV catheter.
- B. Verify that the restraints can be quickly released.
- C. Assess capillary refill distal to the restraints.
- D. Replace the nasogastric tube.
Correct Answer: C
Rationale: When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints. This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
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An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops.What actions should the nurse take first?
- A. Obtain a do not resuscitate prescription.
- B. Set up a family conference to discuss the client's wishes.
- C. Discuss with the client her meaning of heroic measures.
- D. Consult the palliative care team about the client's care.
Correct Answer: C
Rationale: The nurse should first discuss with the client her meaning of heroic measures. This will help the nurse to understand the client's wishes and preferences for her care.
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
- A. Basilar lung sounds that are diminished in the left lung.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Capillary refill of 2 seconds in the lower right foot.
- D. Active bowel sounds in the lower right quadrant.
Correct Answer: A
Rationale: Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome. In this case, the nurse should document the assessment that is not within normal limits, which is 'Basilar lung sounds that are diminished in the left lung.'
A postoperative client has been prescribed three different analgesics for different levels of pain.What is the most important intervention the nurse should take when administering these medications to the client?
- A. Administer each medication at the same time to ensure pain relief.
- B. Administer the medication with the highest dose first, then the others.
- C. Administer the medications as ordered based on the client's pain level.
- D. Administer the medication with the longest duration of action
Correct Answer: C
Rationale: The most important intervention the nurse should take when administering these medications to the client is to assess the client's pain level and administer the appropriate medication based on the level of pain.
A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?
- A. I'm sorry but your son's medical information is none of your business.
- B. The healthcare provider will share this information with you.
- C. I can only give medical information to your son because he is an adult.
- D. I will get these results back from the lab as soon as possible.
Correct Answer: C
Rationale: The best response for the nurse to provide is 'I can only give medical information to your son because he is an adult.' Since the client is 19 years old and considered an adult, the nurse must respect the client's right to privacy and confidentiality.
The healthcare provider prescribes penicillin 800,000 units intramuscularly (IM) for a patient with a streptococcal infection. The vial available is labeled Penicillin 50,000 units/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.).
- A. 10
- B. 12
- C. 14
- D. 16
Correct Answer: D
Rationale: The healthcare provider prescribed 800,000 units of penicillin and the vial available is labeled 50,000 units/mL. To calculate the number of mL to administer, you need to divide the total number of units prescribed (800,000) by the number of units per mL (50,000). This gives you a result of 16 mL.