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The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.
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A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?
- A. Place the client on contact precautions.
- B. Start a high-fiber diet.
- C. Administer an oral steroid.
- D. Make the client NPO.
Correct Answer: D
Rationale: Normal glucose requires no action.
After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?
- A. Request removal initiated by the Health Information Manager.
- B. Make an electronic addendum following the 1400 documentation.
- C. Create an electronic correction after 1400 notes are officially unlocked.
- D. Enter the occurrence after the 1400 notes and identify as 'late entry.'
Correct Answer: D
Rationale: Late entries maintain accuracy.
A 64-year-old female client with a 3-day history of cough and chest pain is admitted for presumed pneumonia. The client has a history of type 2 diabetes mellitus and takes insulin glargine 17 units in the morning and 17 units in the evening. Which of the following actions should the nurse take to prevent medication errors?
- A. Double check all dosage calculations.
- B. nusually large or small doses.
- C. Compare the medication label to the order.
- D. Use at least 2 client identifiers before administering a dose.
- E. Involve and educate clients in medication administration.
- F. Document all medication in the electronic record as soon as it is given.
Correct Answer: A,C,D,E.F
Rationale: Verification and documentation ensure safety.
The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?
- A. Gives the client a hug and says, 'It’s okay to cry when you are sad.'
- B. While touching the client’s forearm, asks, 'Would you like to talk about it?'
- C. I’m sorry to disturb you at a difficult time. This can wait until later.'
- D. This is a bad time. I can see you are upset. I can come back later.'
Correct Answer: B
Rationale: Empathy encourages communication.
The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.
- A. Encourage increased fluid intake and measure urinary output every 8 hours.
- B. Provide comfort measures such as topical warm application and tactile massage.
- C. Determine client’s objective measure of pain using a numerical pain scale.
- D. Assist the client to ambulate as much as possible during waking hours.
- E. Implement a 24-hour schedule of routine administration of prescribed analgesics.
Correct Answer: B,C,E
Rationale: Comfort, assessment, and analgesics manage pain.