Nokea
The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
- A. Keep the medication and see if the client will want to take it later.
- B. Credit the medication back and put it in the client's medication box.
- C. Explain that since the medication is a controlled substance it must be taken.
- D. Have another nurse watch the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal ensures safety and compliance.
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A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
- A. Elevate the area and apply light pressure over the site.
- B. Apply a cold pack to the area for twenty minutes.
- C. Document the site where the medication was given.
- D. Notify the healthcare provider of the allergic response.
Correct Answer: C
Rationale: Documenting confirms normal intradermal reaction.
The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?
- A. Warn the colleague that their actions are unprofessional.
- B. Discuss the action at the next staff meeting.
- C. Communicate the observation to the charge nurse.
- D. File a detailed incident report with the specific facility.
Correct Answer: C
Rationale: Reporting to the charge nurse ensures prompt action.
History and physical
A 78-year-old female was admitted three days ago with a stage 3 pressure wound at the coccyx. The wound was being cared for at home but has increased in severity from a stage 1 to a stage 3.
Nurses Notes
0800
Head-to-toe assessment complete. Vital signs stable. Pressure injury at the coccyx has anasept in the wound base covered with foam. Dressing clean, dry, and intact.
1200
Client returned from occupational therapy for hip pain. Vital signs stable. Wound dressing clean, dry, and intact.
1500
Client called out on the call light. Reported an incontinent episode. Perineal cleaning and linen
Flowsheet
Vital Signs
0800
• Temperature 98°F. (36.7 °C) orally
• Heart rate 82 beats/minute
• Respiratory rate 14 breaths/minute
. Blood pressure 136/62 mm Hg
1200
• Oxygen saturation 99% on room air
• Patri rating of 1 on 0 to 10 scale, located at соссух
• Temperature 98.4 °F. (36.9 °C) orally
• Heart rate 82 beats/minute
Orders
0830
Wound dressing change every Monday, Wednesday, Friday, and PRN:
Cleanse with normal saline and pat dry Apply anasept gel to wound base. Cover with foam dressing
The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.
- A. Gather materials to change soiled items only;
- B. Thoroughly clean wound using normal saline prior to redressing;
- C. Place sterile gauze directly on wound bed;
- D. Apply sterile gloves prior to changing;
- E. Apply sterile foam dressing over wound bed;
Correct Answer:
Rationale: Sterile technique and foam dressing promote healing.
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 is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?
- A. Power flush with 60 mL to remove mucous obstructions.
- B. Slowly irrigate catheter with saline using an infusion pump.
- C. Clamp the catheter for 30 minutes prior to irrigating.
- D. Use a sterile syringe to irrigate with 20 mL normal saline.
Correct Answer: B
Rationale: Slow irrigation safely clears clots and sediment.