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The nurse is preparing to administer medication to a client. After verifying the right medication, dose, route, and time, the nurse should
- A. confirm the client's identity using two client identifiers.
- B. explain the purpose and potential side effects of the medication to the client.
- C. ensure the medication is within its expiration date.
- D. document the medication administration in the client's medical record.
Correct Answer: A
Rationale: Confirming client identity is the next step after verifying medication details to ensure safety.
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A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat:
- A. Within 10 to 15 minutes after the injection.
- B. 1 hour after the injection.
- C. At any time, because timing of meals with lispro injections is unnecessary.
- D. 2 hours before the injection.
Correct Answer: A
Rationale: Insulin lispro is rapid-acting, with onset within 15 minutes. Eating within 10–15 minutes prevents hypoglycemia by matching food intake to insulin action.
A client with ulcerative colitis is prescribed mesalamine (Asacol). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Slight rash.
- C. Worsening diarrhea.
- D. Fatigue.
Correct Answer: C
Rationale: Worsening diarrhea in a client with ulcerative colitis taking mesalamine may indicate a lack of therapeutic response or a serious adverse effect, requiring immediate reporting. Mild headache, slight rash, and fatigue are less urgent but should be monitored. CN: Pharmacological and parenteral therapies; CL: Synthesize
A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which of the following risk factors should be necessary:
- A. Family history.
- B. Lifestyle choices.
- C. Age.
- D. Menopause or hormonal events.
Correct Answer: C
Rationale: Age is the most significant risk factor for cancer, as the incidence of most cancers increases with advancing age due to cumulative genetic and environmental damage.
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
- A. Use a fluorescent light source to assess the skin.
- B. L rescued the skin only when the Braden score is above 12.
- C. Look for skin color that is darker than the surrounding tissue.
- D. Avoid touching the skin during inspection.
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected?
- A. Normal breath sounds.
- B. Prolonged inspiration.
- C. Normal chest movement.
- D. Coarse crackles and rhonchi.
Correct Answer: D
Rationale: COPD exacerbation with infection produces coarse crackles and rhonchi from secretions and airway inflammation. Breath sounds are diminished, expiration is prolonged, and chest movement is reduced.