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The nurse receives a new prescription to administer oxygen at 3 L/minute via a nasal cannula to maintain an oxygen saturation between 90 and 100% for an adult client. The nurse obtains an oxygen saturation reading of 85% and, after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?
- A. Place the client in a Trendelenburg position.
- B. Document the second reading in the client record.
- C. Securely place the prongs of the cannula in the nostrils.
- D. Place the pulse oximeter on the client's earlobe.
Correct Answer: C
Rationale: Proper cannula placement ensures effective oxygen delivery.
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The nurse retrieves hydromorphone 4 mg/mL from an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?
- A. Determine if the expected outcomes were realistic.
- B. Review related professional standards of care.
- C. Obtain current client data to compare with expected outcomes.
- D. Modify the nursing interventions to achieve the client's goals.
Correct Answer: C
Rationale: Comparing data assesses care effectiveness.
The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?
- A. Journaling
- B. Return demonstration.
- C. Role playing.
- D. Analogies.
Correct Answer: C
Rationale: Role-playing builds confidence in handling anger.
While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: IT notification resolves system issues quickly.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
- A. Incorporate verbal analogies.
- B. Offer positive reinforcement.
- C. Provide physical demonstrations.
- D. Use simulation activities.
Correct Answer: D
Rationale: Simulations promote critical thinking.