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What times should the nurse measure vital signs? Select all that apply.
- A. 800
- B. 1000
- C. 1200
- D. 1400
- E. 1600
Correct Answer: A,C,E,G
Rationale: Every 4 hours is standard.
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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 nurse is administering insulin glargine to a client. 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.
When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
- A. Assess strength of deep tendon reflexes.
- B. Determine apical pulse rate and rhythm.
- C. Observe color and amount of urine.
- D. Compare muscle strength bilaterally.
Correct Answer: B
Rationale: Hyperkalemia risks arrhythmias; cardiac monitoring is critical.
The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?
- A. Inspects crutches to ensure rubber tips are intact.
- B. Practices bicep and triceps isometric exercises.
- C. Bears body weight on the palms of hands during the crutch gait.
- D. Progresses to foot touchdown and weight bearing of the affected leg.
Correct Answer: C
Rationale: Inspecting tips ensures safety.
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.