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The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?
- A. Expel the air in the prefilled syringe prior to injection.
- B. Rotate injections between the abdomen and gluteal areas.
- C. Massage the injection site to increase absorption.
- D. Inject in the abdominal area at least 2 inches from the umbilicus.
Correct Answer: D
Rationale: Abdominal site ensures absorption.
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An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Send the UAP to be fitted for a particulate filter mask immediately.
- B. Instruct the UAP that a standard face mask is sufficient.
- C. Before changing assignments, determine which staff members have fitted particulate filter masks.
- D. Advise the UAP to wear a standard face mask to obtain vital signs.
Correct Answer: B
Rationale: Standard mask suffices for droplet precautions.
The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?
- A. Send an email to facility administrators reporting the action.
- B. Dispose of the copies and continue with client care assignments.
- C. Warn the colleague that copying health information is unlawful.
- D. Communicate the colleague’s activities to the unit charge nurse.
Correct Answer: D
Rationale: Reporting ensures intervention.
A 45-year-old client with breast cancer which has metastasized is receiving hospice care. The client is at home and the family is concerned about their loved one. The nurse assesses the client. Which of the following signs indicate that the client is near death?
- A. Decreased muscle tone, relaxed jaw muscles, sagging mouth.
- B. Urine output is clear yellow.
- C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern).
- D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).
Correct Answer: A,C,D
Rationale: Muscle tone, breathing, and secretions indicate nearing death.
The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?
- A. Offering therapeutic support to a grieving family.
- B. Obtaining clarification from a client’s healthcare power-of-attorney.
- C. Reporting a change in a client’s condition to the healthcare provider.
- D. Completing discharge teaching to a client and family members.
Correct Answer: C
Rationale: SBAR is for clinical communication.
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
- A. Active bowel sounds in the lower right quadrant.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Basilar lung sounds that are diminished in the left lung.
- D. Capillary refill of 2 seconds in the lower right foot.
Correct Answer: C
Rationale: Abnormal findings are documented.