Nokea
The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate?
- A. Assign the same nurses and caregivers to the child each day
- B. Avoid mentioning the loved one's death in the child's presence
- C. Explain the importance of being with the child to the parents
- D. Schedule time each day for age-appropriate play
Correct Answer: B
Rationale: Avoiding discussion of the grandparent's death may confuse the child or hinder grieving. Open, age-appropriate communication supports emotional processing.
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The nurse has attended a staff education program about needlestick injuries. Which of the following statements by the nurse would require follow-up?
- A. Needlestick injuries should be reported to the employee health clinic.
- B. Needlestick injuries can be prevented by recapping needles after use.
- C. Postexposure prophylaxis may be prescribed after a needlestick injury occurs.
- D. Soap and water should be used to wash the affected area after a needlestick injury occurs.
Correct Answer: B
Rationale: Recapping needles increases the risk of injury and is not recommended. Needles should be disposed of in sharps containers immediately after use.
A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action?
- A. Assess the condition of the IV site
- B. Check 2 client identifiers before administering medications
- C. Consult a medication guide for compatibility
- D. Wash hands prior to administering medications
Correct Answer: C
Rationale: Ensuring medication compatibility prevents chemical interactions or precipitation in the IV line, which could harm the client or obstruct the catheter.
The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse?
- A. pruritic rash
- B. dry, hacking cough
- C. chronic fatigue
- D. elevated temperature
Correct Answer: D
Rationale: It is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature.
The nurse prepares to administer an oral expectorant to a client with pneumonia. The client tells the nurse, 'That pill is too big. I won't be able to swallow it.' What is the best action by the nurse?
- A. Contact the pharmacy and request the liquid form of the medication.
- B. Crush the medication and place it in a small amount of applesauce.
- C. Instruct the client to tuck chin to chest while swallowing the tablet.
- D. Obtain a new prescription for the liquid form of the medication.
Correct Answer: A
Rationale: Contacting the pharmacy for a liquid form addresses the client's difficulty swallowing the pill, ensuring medication adherence without altering the drug inappropriately.
A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene?
- A. Encourages the client to drink extra fluids while taking ferrous sulfate
- B. Offers the client orange juice for administration of ferrous sulfate
- C. Plans to administer ferrous sulfate one hour before breakfast
- D. Prepares to administer a prescribed calcium supplement with ferrous sulfate
Correct Answer: D
Rationale: Calcium inhibits iron absorption, so administering ferrous sulfate with a calcium supplement reduces its effectiveness, requiring intervention.