Nokea
The nurse is preparing to administer an antihypertensive and an anticoagulant to a client. Which should the nurse do first before administering the medication?
- A. verify the client's allergies
- B. verify the client's name and room number
- C. ask the client to state her name and date of birth
- D. scan the client's wristband and medication barcode
- E. verify the client's name, date of birth, and medical record number with the medication order
Correct Answer: A
Rationale: Verifying allergies first ensures safety by preventing allergic reactions before proceeding with identification.
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Medical management of a client with acute diverticulitis should include which treatment?
- A. increased fiber in diet
- B. administration of antibiotics
- C. pain medication administration
- D. liquid diet for 1-2 days
Correct Answer: B
Rationale: Antibiotics are a cornerstone of treatment for acute diverticulitis to address infection. Increased fiber (A) is for prevention, not acute management, while pain medication (C) and liquid diet (D) are supportive but not primary.
The nurse has given a client an injection and then notes that the sharps container is full. Which is the correct action by the nurse?
- A. exchange the full container for a new one
- B. place the syringe on top of the container so it will not roll off
- C. force the syringe into the top of the container as well as it will fit
- D. put the syringe into her pocket and dispose of it in another room
Correct Answer: A
Rationale: Exchanging the full sharps container ensures safe disposal and prevents injury.
The nurse is caring for a client with an internal cervical radiation implant. When performing morning care, the nurse notes the implant lying on the bed. Which nursing action should be done first?
- A. notify the health care provider
- B. apply gloves and attempt to reinsert the implant
- C. retrieve the implant with long-handled forceps and place into a lead container
- D. don a lead apron and retrieve the implant with long-handled forceps and place into a lead container
Correct Answer: C
Rationale: Using long-handled forceps to place the implant in a lead container minimizes exposure. Reinsertion is unsafe, and a lead apron is secondary to immediate containment.
A group of nurses are reviewing surgical asepsis. Which statement by one of the nurses requires further teaching on the topic?
- A. Full-strength chlorhexidine will sterilize the skin.
- B. The edges of a sterile field are considered unsterile.
- C. If a sterile object touches an unsterile object, the sterile object is considered contaminated.
- D. Sterile objects that are out of view or below waist level are considered unsterile.
- E. Airborne microorganisms can contaminate sterile objects and make them unsterile.
Correct Answer: A
Rationale: Chlorhexidine reduces bacteria but does not sterilize skin. Other statements are correct principles of surgical asepsis.
The nurse is reviewing the facility's emergency preparedness plan. Which statement is true regarding emergency preparedness?
- A. Nurses play supporting roles during and after a disaster or emergency.
- B. The critical incident stress debriefing team analyzes what went wrong and what went right with the plan.
- C. The administrative review meets with team members shortly after the event to promote effective coping strategies to staff.
- D. Without stress management and intervention during and after an event, staff members are at risk of developing post-traumatic stress disorder (PTSD).
Correct Answer: D
Rationale: Stress management is critical to prevent PTSD in staff post-disaster. Nurses have active roles, debriefing teams focus on coping, and administrative reviews assess processes, not coping.