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After a week of bed rest, a client is being assisted to a chair for the first time.The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?
- A. Determine how the client feels.
- B. Support the client when rising.
- C. Offer a pair of non-skid socks.
- D. Place the chair by the bed.
Correct Answer: A
Rationale: After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels. This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.
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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.
When using 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. Compare muscle strength bilaterally.
- B. Determine apical pulse rate and rhythm.
- C. Measure color and amount of urine.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hyperkalemia can lead to life-threatening cardiac conduction disturbances. Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies.Which of the following is most useful for the nurse to include?
- A. Providing physical demonstration.
- B. Using simulation activities.
- C. Incorporating verbal analogies.
- D. Offering positive reinforcement.
Correct Answer: B
Rationale: Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences.
The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer.Which action should the nurse implement?
- A. Remind the UAP to locate the thermometer before gently inserting the ear.
- B. Demonstrate the correct technique for pulling the client's auricle up and back.
- C. Advise the UAP to hold the thermometer securely in place to obtain the measurement.
- D. Use positive reinforcement to affirm that the procedure being performed correctly.
Correct Answer: D
Rationale: The UAP is correctly pulling the client's auricle up and back and preparing to insert the thermometer.