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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.
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A nurse is reviewing error prevention techniques that would have helped to avoid a medication error. Which technique is most effective?
- 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.
Correct Answer: D
Rationale: Identifiers prevent misidentification.
The nurse attaches a pulse oximeter to a client’s finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
- A. 2+ edema of fingers and hands.
- B. Capillary refill time is 2 seconds.
- C. Blood pressure is 142/88 mm Hg.
- D. Radial pulse volume is 3+.
Correct Answer: A
Rationale: Edema distorts oximeter readings.
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.
A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home?
- A. Have the client demonstrate prescribed wound care.
- B. After each instruction, ask if the client understands.
- C. Have an interpreter repeat the wound care instructions.
- D. Provide written instructions in the client’s native language.
Correct Answer: A
Rationale: Demonstration confirms skill.
The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to ask the client about sexual activity. Which approach is best for the nurse to use?
- A. Begin with queries that are less sensitive in nature.
- B. Ask queries in a vague, non-specific format.
- C. Get the most difficult queries over with first.
- D. Share personal values to put the client at ease.
Correct Answer: A
Rationale: Less sensitive queries build rapport.