Nokea
When preparing to administer eye drops to a school-age child, what actions should a nurse take?
- A. 52341
- B. 53241
- C. 35241
- D. 14325
Correct Answer: A
Rationale: The correct sequence for administering eye drops to a school-age child is as follows: 5. Place the child in a sitting position, 2. Ask the child to look upward, 3. Pull the lower eyelid downward, 4. Instill the drops of medication, and 1. Apply pressure to the lacrimal punctum. Placing the child in a sitting position helps with stability and ease of access. Asking the child to look upward helps expose the conjunctival sac. Pulling the lower eyelid downward creates a pouch for instilling the drops. Instilling the drops of medication directly into the pouch ensures proper administration, and applying pressure to the lacrimal punctum prevents systemic absorption and promotes local action of the medication.
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A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?
- A. Use a professional interpreter service
- B. Nurse to interpret
- C. Provide translation services for a nominal fee to clients
- D. Evaluate the clients' understanding at regular intervals
Correct Answer: B
Rationale: In situations where there is a language barrier between healthcare providers and patients, it is essential to ensure accurate communication. Using professional interpreter services is the most appropriate choice to ensure clear and precise communication. Relying on the client's children for interpretation may not guarantee accurate or confidential communication. Asking the nurse to interpret can lead to miscommunication or misunderstanding of important medical information. Providing translation services for a nominal fee to clients may not always be feasible or culturally appropriate. Regularly evaluating the client's understanding helps ensure that information is effectively communicated and comprehended.
A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching?
- A. ''OOB with assistance for breakfast''
- B. ''Given 2 mg MSO4 IM for report of pain''
- C. ''Dressing changed qd''
- D. ''Administered 8 units of regular insulin subcutaneously''
Correct Answer: D
Rationale: The correct answer demonstrates proper documentation by specifying the action taken ('Administered'), the dose ('8 units'), the medication ('regular insulin'), and the route of administration ('subcutaneously'). This notation ensures clarity and accuracy in recording the nursing intervention, aligning with best practices in documentation.
A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy?
- A. Teaching parenting skills to expectant mothers and their partners.
- B. Conducting mental health screenings at the local community center
- C. Referring clients with obesity to community exercise programs
- D. Providing crisis intervention through a mobile counseling unit
Correct Answer: A
Rationale: The correct answer is teaching parenting skills to expectant mothers and their partners. This intervention is a primary prevention strategy aimed at educating individuals before a problem or condition develops. By teaching parenting skills, the nurse is promoting healthy behaviors and relationships, which can prevent future issues. The other options involve secondary or tertiary prevention strategies by identifying and treating existing conditions or providing interventions after a problem has occurred.
A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the professional take to identify the client?
- A. Match the client's blood type with the type and cross-match specimens
- B. Confirm the provider's prescription matches the number on the blood component
- C. Ask the client to state their blood type and the date of their last blood donation
- D. Ensure that the client's identification band matches the number on the blood unit
Correct Answer: A
Rationale: When preparing to administer an autologous blood product, it is crucial to correctly identify the client to prevent errors. Matching the client's blood type with the type and cross-match specimens ensures that the blood product is intended for the correct recipient. This step helps in verifying the patient's identity and avoiding any transfusion-related complications. Confirming the blood type through type and cross-matching is a standard practice to ensure patient safety during blood transfusions.
A client reports that the medication the nurse is administering appears different than what they take at home. Which of the following responses should the nurse take?
- A. Did the doctor discuss with you that there was a change in this medication?
- B. I recommend that you take this medication as prescribed
- C. Do you know why this medication is being prescribed to you?
- D. I will call the pharmacist now to check on this medication
Correct Answer: A
Rationale: When a client reports that the medication appears different than what they take at home, it is crucial for the nurse to ensure the safety and accuracy of the medication being administered. The most appropriate action for the nurse to take in this situation is to call the pharmacist to verify the medication, dosage, and any potential changes. This proactive step helps prevent medication errors and ensures the client's safety and well-being.