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An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?
- A. Apply a barrier ointment to intact areas that may be exposed to moisture.
- B. Determine the size and depth of skin breakdown over the sacral area.
- C. Complete a functional assessment of the client's self-care abilities.
- D. Establish a toileting schedule to decrease episodes of incontinence.
Correct Answer: B
Rationale: Assessing breakdown severity guides treatment planning.
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During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Send a list of medication allergies to the pharmacy.
- B. Secure an allergy bracelet around the client's wrist.
- C. Notify the dietary department of the client's fruit allergy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: B
Rationale: Allergy bracelet ensures immediate awareness.
A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?
- A. Ask the UAP to offer a backrub to the client.
- B. Reassess the client and the level of pain.
- C. Tell the client the medication needs more time to work.
- D. Encourage the client to focus on taking deep breaths.
Correct Answer: B
Rationale: Reassessing pain evaluates medication effectiveness.
The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
- A. White blood cell count.
- B. Serum sodium levels.
- C. Serum potassium levels.
- D. Creatinine clearance.
Correct Answer: B
Rationale: Excess water dilutes sodium, risking hyponatremia.
The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?
- A. Use firm pressure to pass the tube through the glottis.
- B. Have the client tilt head backward to open the passage.
- C. Give the client a few sips of water to drink.
- D. Remove the tube and attempt reinsertion.
Correct Answer: D
Rationale: Removing and reinserting prevents discomfort and harm.
While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: Notifying IT ensures prompt system resolution.