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The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of safe, proficient nursing practice?
- A. Verify the order for the medication. Prior to giving the medication the nurse should say, 'Please state your name.'
- B. Upon entering the room the nurse should ask: 'What is your name? What allergies do you have?' and then check the client's name band and allergy band.
- C. As the room is entered say 'What is your name?' then check the client's name band.
- D. Verify the client's allergies on the chart and confirm the client's name on the name band.
Correct Answer: B
Rationale: Asking the client to state their name and allergies, then verifying with the name band and allergy band, ensures accurate identification and safety.
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The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
- A. Decreased carbohydrates and fat
- B. Decreased sodium and potassium
- C. Increased potassium and protein
- D. Increased sodium and fluids
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
Which of these clients is at highest risk for contracting a tuberculosis infection?
- A. A nurse who is immune-suppressed from chemotherapy
- B. A nursing student with a negative purified protein derivative (PPD) test
- C. An elderly client in a nursing home who has never been tested for TB
- D. A health care worker who has a positive PPD test but negative chest x-ray
Correct Answer: A
Rationale: The immune-suppressed nurse undergoing chemotherapy is at the highest risk for contracting tuberculosis due to a weakened immune system, which reduces the ability to fight infections like TB.
The experienced nurse is observing the new nurse providing care to the hospitalized cheat. Which action requires the experienced nurse to intervene to ensure client safety?
- A. Turns on the client's bathroom light and turns out the room lights after settling the client for sleep
- B. Checks the client's room number and name on the name band to verify client identity prior to giving a medication
- C. Stirs thickening powder into the glass of juice and cup of milk before giving these to the client who has dysphagia
- D. Delays the HCP from performing a thoracentesis by calling "a timeout" to verify the client's identity, consent, procedure, and site
Correct Answer: B
Rationale: Room number is not a unique client identifier. The nurse should use two unique identifiers, such as the client's name and medical record number, to verify identity before medication administration.
A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
- A. Explain to the client that the dentures must come out as they may get lost or broken in operating room
- B. Ask the client if there are second thoughts about having the procedure
- C. Notify the anesthesia department and the surgeon of the client's refusal
- D. Ask the client if the preference would be to remove the dentures in the operating room receiving area
Correct Answer: D
Rationale: Ask the client if the preference would be to remove the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept.
After securing the client's safety from a faulty electric bed, the nurse should take which action?
- A. Discuss the matter with the client's significant others.
- B. Document the incident in the client's record in detail.
- C. Notify the physician.
- D. Prepare an incident report.
Correct Answer: D
Rationale: After the situation is safe for the client, the nurse should record the occurrence on an incident form according to the agency protocol.