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The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?
- A. Gives the client a hug and says, 'It’s okay to cry when you are sad.'
- B. While touching the client’s forearm, asks, 'Would you like to talk about it?'
- C. I’m sorry to disturb you at a difficult time. This can wait until later.'
- D. This is a bad time. I can see you are upset. I can come back later.'
Correct Answer: B
Rationale: Empathy encourages communication.
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A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?
- A. Place the client on contact precautions.
- B. Start a high-fiber diet.
- C. Administer an oral steroid.
- D. Make the client NPO.
Correct Answer: D
Rationale: Normal glucose requires no action.
A 64-year-old female client with a 3-day history of cough and chest pain is admitted for presumed pneumonia. The client has a history of type 2 diabetes mellitus and takes insulin glargine 17 units in the morning and 17 units in the evening. Which of the following actions should the nurse take to prevent medication errors?
- A. Double check all dosage calculations.
- B. nusually large or small doses.
- C. Compare the medication label to the order.
- D. Use at least 2 client identifiers before administering a dose.
- E. Involve and educate clients in medication administration.
- F. Document all medication in the electronic record as soon as it is given.
Correct Answer: A,C,D,E.F
Rationale: Verification and documentation ensure safety.
A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking about the client’s laboratory results. Which response is best for the nurse to provide?
- A. The healthcare provider will share this information with you.'
- B. I’m sorry, but your child’s medical information is none of your business.'
- C. I can give you those results as soon as I get them back from the laboratory.'
- D. I can only give medical information to your child because they are legally an adult.'
Correct Answer: D
Rationale: Emancipated minors have autonomy.
A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled 'Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL.' How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)
Correct Answer: 1
Rationale: 30 mg ÷ (30 mg/15 mL) = 1 tablespoon.
The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
- A. Verify placement of pulse oximeter.
- B. Increase the oxygen to 3 L/minute.
- C. Remove nasal cannula.
- D. Switch to a non-rebreather mask.
Correct Answer: A
Rationale: Verifying placement ensures accurate readings.