Nokea
The nurse on the telemetry unit is preparing client medications in the medication room. Which of the following actions should the nurse perform to be consistent with client safety practices related to medication administration? Select all that apply.
- A. Confirm the client's identity, medication, dosage, time, and route prior to medication administration
- B. Do not administer any medication that is damaged or has an unreadable label
- C. Place all medications in a dispensing cup before taking them to a client's room
- D. Review laboratory values before administering anticoagulants
- E. Wear gloves when handling transdermal medication patches
Correct Answer: A,B,D,E
Rationale: These actions align with safe medication administration practices: verifying the 'five rights' (A), ensuring medication integrity (B), checking relevant lab values for anticoagulants (D), and using gloves to prevent absorption of transdermal medications (E).
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Which instructions should the nurse include when reinforcing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply.
- A. Avoid foods that may cause epigastric distress such as spicy or acidic foods.
- B. It is best if you refrain from consuming alcohol products.
- C. Report black tarry stools to your health care provider immediately
- D. Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days.
- E. You may take over-the-counter drugs such as aspirin if you have mild epigastric pain.
Correct Answer: A,B,C,D
Rationale: Avoiding irritants (A), abstaining from alcohol (B), reporting melena (C), and completing the antibiotic regimen (D) are critical for managing H. pylori-related peptic ulcer disease.
The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse?
- A. pruritic rash
- B. dry, hacking cough
- C. chronic fatigue
- D. elevated temperature
Correct Answer: D
Rationale: It is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature.
A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?
- A. With acceptance and views the victim's comment as an indication that their marriage is in trouble
- B. With fear of rejection causing increased rage toward the victim
- C. With a new commitment to seek counseling to assist with their marital problems
- D. With relief, and welcomes the separation as a means to have some personal time
Correct Answer: B
Rationale: With fear of rejection causing increased rage toward the victim. Fear of abandonment often escalates abusive behavior.
The nurse in a long-term care facility is talking with a client with multiple sclerosis who states, 'I want to live in my own home again.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do you have family or friends who could live with you?
- B. I will refer you to a local home-health agency.
- C. How will you manage your care at home?
- D. Tell me more about your concerns.
Correct Answer: D
Rationale: Encouraging the client to express their concerns promotes client-centered care and helps the nurse understand the client's motivations and needs for returning home.
The nurse is assisting with the care of four clients with diabetes mellitus. Which of the following prescriptions should the nurse clarify with the health care provider?
- A. 10 units regular insulin IV push for serum glucose level >250 mg/dL (13.9 mmol/L)
- B. 14 units glargine insulin subcutaneous injection every night at 2000
- C. 18 units aspart insulin subcutaneous injection 15 minutes before breakfast
- D. 20 units NPH insulin IV push administered every morning at 700
Correct Answer: D
Rationale: NPH insulin is not administered IV, as it is a suspension and can cause embolism or erratic absorption. This prescription requires clarification.