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The nurse is new to the resident facility and is administering medications. One of the clients does not have a readable identification band in place. What should the nurse do?
- A. Ask the client what his name is
- B. Ask the client if he is Mr.
- C. Ask the roommate if this is Mr.
- D. Check the bed tag for the name
Correct Answer: C
Rationale: Asking the roommate provides a reliable secondary identifier in the absence of a readable ID band, ensuring safe medication administration. Self-identification or bed tags are less secure.
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The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend exercises
- A. Isometric
- B. Range of motion
- C. Aerobic
- D. Isotonic
Correct Answer: A
Rationale: Isometric. The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e., instruct the client to alternately contract and relax muscles without moving the affected part.
The nurse is feeding a client who experienced a right-sided stroke and has dysphagia and hemianopsia. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Encourage the client to turn the head to the left occasionally while eating
- B. Add milk to the client's mashed potatoes to make the consistency thinner.
- C. Provide a straw for the client to use while drinking a fruit smoothie.
- D. Place food on the stronger side of the client's mouth
- E. Assist the client to sit in an upright position.
Correct Answer: D,E
Rationale: Placing food on the stronger side and upright positioning reduce aspiration risk. Head turning may not help right-sided stroke, thinning food increases aspiration, and straws are unsafe.
The nurse is reinforcing teaching of proper technique for colostomy irrigation for the home health client. Which client action indicates that further instruction is required?
- A. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place
- B. Fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing
- C. Hangs the irrigation container on a hook at the level of the shoulder approximately 18-24 inches above the stoma
- D. Slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs
Correct Answer: A
Rationale: Using an enema set is incorrect; a cone-tipped irrigator is required for safe colostomy irrigation. Water volume , height , and clamping are correct.
The nurse prepares for a Denver Screening of a 3 year-old child in the clinic. The mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the purpose of the Denver?
- A. It measures a child's intelligence.
- B. It assesses a child's development.
- C. It evaluates psychological responses.
- D. It helps to determine problems.
Correct Answer: B
Rationale: It assesses a child's development. The Denver test screens for developmental milestones in young children.
A 2-month-old infant has been admitted to the hospital with suspected shaken baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse expects to encounter which of these clinical findings?
- A. A reported history of recent trauma
- B. Abdominal bruising
- C. External signs of trauma
- D. Irritability and vomiting
Correct Answer: D
Rationale: Shaken baby syndrome often presents with irritability and vomiting due to intracranial injury, without external trauma , abdominal bruising , or reported trauma .