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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.
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The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?
- A. White blood cell count.
- B. Serum sodium levels.
- C. Serum potassium levels.
- D. Creatinine clearance.
Correct Answer: B
Rationale: Excess water dilutes sodium, risking hyponatremia.
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: Notifying IT ensures prompt system resolution.
The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?
- A. Power flush with 60 mL to remove mucous obstructions.
- B. Slowly irrigate catheter with saline using an infusion pump.
- C. Clamp the catheter for 30 minutes prior to irrigating.
- D. Use a sterile syringe to irrigate with 20 mL normal saline.
Correct Answer: B
Rationale: Slow irrigation safely clears clots and sediment.
The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?
- A. Obtain permission from the nursing supervisor to transport the client without protective equipment.
- B. Place protective goggles over the client's eyeglasses after first positioning the face mask.
- C. Instruct the client about the need to wear a fitted respirator-style mask when leaving the room.
- D. Secure a surgical face mask over the bridge of the client's nose just below the eyeglasses.
Correct Answer: D
Rationale: Surgical mask ensures droplet precaution compliance.
After a seven-day treatment with an IV antibiotic, the healthcare provider discharges a client from the hospital and writes a prescription for an oral antibiotic. While providing discharge instructions, the nurse notes that the dosage for the oral antibiotic is significantly higher than the IV antibiotic. Which resource should the nurse use first in resolving the situation?
- A. Hospital pharmacist.
- B. Healthcare provider.
- C. Medication reference guide.
- D. Nursing unit charge nurse.
Correct Answer: B
Rationale: Provider clarifies prescription accuracy.