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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. Explain that since the medication is a controlled substance, it must be taken.
- B. Credit the medication back and put it in the client's medication box.
- C. Keep the medication and see if the client will want to take it later.
- D. Have another nurse witness the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal prevents misuse of controlled substances.
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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 home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails?
- A. Shufling gait.
- B. Urinary incontinence.
- C. Syncope when bending.
- D. Hand tremors.
Correct Answer: A,C,D
Rationale: Mobility and dexterity issues necessitate foot care assistance.
The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?
- A. Increase the liter flow of oxygen.
- B. Encourage the client to take deep breaths.
- C. Remove the mask to deflate the bag.
- D. Document the assessment data.
Correct Answer: A
Rationale: Increasing flow ensures oxygen delivery.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
- A. Complete the intermittent suction of the nasopharynx.
- B. Apply an oxygen mask over the client's nose and mouth.
- C. Reposition the pulse oximeter clip to obtain a new reading.
- D. Stop suctioning until the pulse oximeter reading is above 95%.
Correct Answer: A
Rationale: Stable saturation allows safe continuation of suctioning.
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.