Nokea
A nurse is preparing to administer a med to a client. The med was scheduled for administration at 0900. Which of the following are acceptable administration times for this med? Select all.
- A. 905
- B. 825
- C. 1,000
- D. 840
- E. 935
Correct Answer: A,D
Rationale: The correct answers are A and D. Medications can generally be administered within 30 minutes before or after the scheduled time. A (905) and D (840) fall within this window for a 0900 scheduled administration. B (825) is too early, C (1,000) is too late, and E (935) is also too late. It's important to administer medications close to the scheduled time to maintain therapeutic levels in the body.
You may also like to solve these questions
A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?
- A. "Assault"
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: A
Rationale: The correct answer is A: "Assault." Assault is the intentional act that creates fear of imminent harmful or offensive contact. In this scenario, the AP's threat of putting a diaper on the client if he does not use the urinal properly next time constitutes assault as it instills fear in the client. Choice B, Battery, involves actual harmful or offensive contact, which is not present here. Choice C, False Imprisonment, involves restricting someone's freedom of movement, which is not happening in this scenario. Choice D, Invasion of Privacy, is not applicable as the situation does not involve a violation of the client's privacy.
A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.
- A. Increase in incisional pain
- B. Fever & chills
- C. Reddened wound edges
- D. Increase in serosanguineous drainage
- E. Decrease in thirst
Correct Answer: A, B, C
Rationale: The correct assessment findings the nurse should expect in a client suspected of having an incisional wound infection include: A) Increase in incisional pain: Infection can cause localized pain. B) Fever & chills: Systemic signs of infection. C) Reddened wound edges: Classic sign of wound infection. Incorrect choices: D) Increase in serosanguineous drainage: This is more indicative of normal wound healing. E) Decrease in thirst: Unrelated to wound infection. Overall, pain, fever, and redness are key signs of infection that the nurse should look out for.
A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
- A. Don't measure the client's temperature rectally.'
- B. Count the client's radial pulse for 30 seconds & multiply by 2.'
- C. Don't let the client know you are counting her respirations.'
- D. Let the client rest for 5 minutes before you measure her BP.'
Correct Answer: A
Rationale: Correct Answer: A: Don't measure the client's temperature rectally.
Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa. Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.
Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.
A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she would ask the client to close his eyes & identify which of the following items?
- A. A word she whispers 30cm from his ear
- B. A number she traces on the palm of his hand
- C. The vibration of a tuning fork she places on his foot
- D. A familiar object she places in his hand
Correct Answer: D
Rationale: The correct answer is D: A familiar object she places in his hand. Stereognosis is the ability to recognize objects by touch without visual cues. By asking the client to identify a familiar object placed in his hand with his eyes closed, the nurse is testing his ability to perceive and interpret tactile sensations. This assessment helps evaluate the client's sensory perception and integration in the neurosensory system. The other choices are incorrect because they do not specifically assess stereognosis. Choice A involves auditory perception, choice B involves tactile perception but not recognition of objects, and choice C involves vibratory perception rather than object recognition through touch.
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.