The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?
- A. Inspects crutches to ensure rubber tips are intact.
- B. Practices bicep and triceps isometric exercises.
- C. Bears body weight on the palms of hands during the crutch gait.
- D. Progresses to foot touchdown and weight bearing of the affected leg.
Correct Answer: C
Rationale: Inspecting tips ensures safety.
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The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which requires self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
- A. The client will demonstrate the ability to change the ostomy bag in two days.
- B. The client attempts to self-administer insulin but is unable to perform the injection.
- C. The client’s breath sounds will be auscultated by the nurse every 4 hours.
- D. The client will adhere to the medication regimen after discharge.
Correct Answer: D
Rationale: Medication adherence manages hyperglycemia.
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 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 nurse is reviewing error prevention techniques that would have helped to avoid a medication error. Which technique is most effective?
- 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.
Correct Answer: D
Rationale: Identifiers prevent misidentification.
After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?
- A. Request removal initiated by the Health Information Manager.
- B. Make an electronic addendum following the 1400 documentation.
- C. Create an electronic correction after 1400 notes are officially unlocked.
- D. Enter the occurrence after the 1400 notes and identify as 'late entry.'
Correct Answer: D
Rationale: Late entries maintain accuracy.
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