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Which nursing action will best promote patient safety when administering medications?
- A. Check the patient's wristband before administering medications.
- B. Confirm the patient's allergies prior to administration.
- C. Document the medications immediately after administration.
- D. Prepare medications at the medication cart to minimize distractions.
Correct Answer: B
Rationale: Confirming the patient's allergies before administering medications is crucial for patient safety as it helps prevent adverse reactions. Checking the patient's wristband is important for identification but may not directly impact medication safety. Documenting medications after administration is necessary but does not primarily promote safety during administration. Preparing medications at the medication cart, rather than the nurse's station, is preferred to ensure accuracy and proper medication handling, but it is not directly related to confirming allergies for safety.
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The nurse is caring for a group of medical-surgical patients. A fire has been reported in an adjacent wing of the hospital. What should the nurse do to ensure the patients' safety?
- A. Wait until the fire department arrives before taking action.
- B. Close all doors.
- C. Identify evacuation routes.
- D. Move bedridden patients in their beds.
Correct Answer: B
Rationale: During a fire emergency, it is crucial to close all doors to contain smoke and fire, helping to protect the patients. This action can prevent the spread of fire and smoke to the area where patients are located. Identifying evacuation routes is also important for a timely and orderly evacuation if necessary. Waiting for the fire department to arrive before taking action (Choice A) can waste valuable time and put patients at risk. Moving bedridden patients in their beds (Choice D) can be dangerous during a fire and should be avoided as it can expose patients and staff to more risks.
Which nursing action is essential when administering a blood transfusion?
- A. Ensure the blood is administered within 4 hours.
- B. Check the patient's vital signs every 30 minutes during the transfusion.
- C. Administer the transfusion at a slow rate for the first 15 minutes.
- D. Document the transfusion in the patient's medical record immediately after administration.
Correct Answer: C
Rationale: The correct answer is to administer the transfusion at a slow rate for the first 15 minutes. This practice is crucial as it helps in detecting any adverse reactions early on. Checking the patient's vital signs every 30 minutes (choice B) is important but not as essential as ensuring a slow rate at the beginning. Administering blood within 4 hours (choice A) is a standard practice but not directly related to the initial administration. Documenting the transfusion immediately (choice D) is necessary but does not directly impact the safety of the initial administration.
A patient is experiencing shortness of breath. What is the nurse's immediate action?
- A. Assist the patient into a high Fowler's position.
- B. Administer oxygen at 2 liters per minute via nasal cannula.
- C. Encourage the patient to take deep breaths and cough.
- D. Assess the patient's lung sounds.
Correct Answer: B
Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.
A nurse witnesses a colleague administering the wrong IV solution to a client. What should the nurse do first?
- A. Complete an incident report.
- B. Ask the colleague if they intend to report the error.
- C. Call the healthcare provider to notify them of the error.
- D. Notify the supervisor about the situation.
Correct Answer: B
Rationale: The correct first step for the nurse to take in this situation is to ask the colleague if they intend to report the error. It is important to address the error promptly and directly with the colleague involved to ensure that the appropriate actions are taken to correct the mistake and prevent harm to the client. Completing an incident report, calling the healthcare provider, or notifying the supervisor can be done after discussing the error with the colleague. Immediate communication with the colleague directly involved in the error is crucial to address the situation effectively.
A nurse provides instructions to a client about preventing injury while using crutches. What should the nurse tell the client to avoid?
- A. An abnormal stance
- B. Injury to the nerves
- C. A fall and further injury
- D. Skin breakdown
Correct Answer: B
Rationale: The correct answer is B: Injury to the nerves. Resting the underside of the arm on the crutch pad can injure the nerves. Choice A, an abnormal stance, is not directly related to nerve injury while using crutches. Choice C, a fall and further injury, is a general risk associated with improper crutch use but does not specifically address nerve injury. Choice D, skin breakdown, is a concern related to pressure ulcers but not the primary focus when discussing injury prevention related to crutch use.