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During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Secure an allergy bracelet around the client's wrist.
- B. Notify the dietary department of the client's fruit allergy.
- C. Send a list of medication allergies to the pharmacy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: A
Rationale: Allergy bracelet prevents immediate exposure.
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When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume?
- A. Oatmeal, cream of wheat, pureed liquid.
- B. Pureed beans, liquid protein supplements, milkshake.
- C. Pureed carrots, creamed soup, ice cream.
- D. Carbonated drinks, gelatin, broth.
- E. Water, tea, ice chips.
Correct Answer: D,E
Rationale: Clear liquids are transparent and easily digested.
When interviewing a client about sexuality/reproductive function, which is the best approach for the nurse to use?
- A. Get the most difficult questions over with first.
- B. Begin with questions that are less sensitive in nature.
- C. Ask questions in a vague, non-specific format.
- D. Share personal values to put the client at ease.
Correct Answer: B
Rationale: Less sensitive questions build rapport.
When assessing a client with a serum potassium level of 2.5 mEq/L, which intervention is most important for the nurse to implement?
- A. Observe color and amount of urine.
- B. Determine apical pulse rate and rhythm.
- C. Compare muscle strength bilaterally.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hypokalemia risks arrhythmias; pulse is critical.
The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?
- A. Give the patient 8 ounces (240 mL) of water to drink.
- B. Notify the healthcare provider.
- C. Check the drainage tubing for a kink.
- D. Review the intake and output record.
Correct Answer: C
Rationale: Checking tubing addresses potential obstruction.
The nurse is planning assignments for the staff on a medical-surgical unit. Which task should the nurse assign to the practical nurse (PN)?
- A. Complete an admission assessment.
- B. Access a central venous line.
- C. Reinforce discharge teaching.
- D. Initiate blood product infusions.
Correct Answer: C
Rationale: PNs can reinforce teaching within scope.