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Which of the following actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.
- A. Have the client state his or her name.
- B. Check the name on the arm band with the name on the medication.
- C. Learn to recognize the client.
- D. Check the client's room number.
- E. Compare the date of birth on the client's chart to the date of birth on the client's armband.
Correct Answer: A,B,E
Rationale: Using two identifiers, such as the client's name, armband, and date of birth, ensures accurate medication administration. Room number and visual recognition are not reliable.
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The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
- A. Inappropriate laughter.
- B. An exaggerated sense of well-being.
- C. Slurring of words when excited.
- D. Visual hallucinations.
Correct Answer: B
Rationale: Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.
A client with a history of cardiac problems is having severe chest pain. What should be nurse's first response?
- A. Notify the physician
- B. Administer an analgesic to control the pain
- C. Assess the client's pain
- D. Start oxygen at 2L minute via nasal cannula
Correct Answer: C
Rationale: Assessing the client's chest pain is the first step to determine its nature and severity, guiding further actions like notifying the physician or administering oxygen or analgesics.
While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal delivery, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the physician because these findings indicate which of the following?
- A. Biliary atresia.
- B. Rh isoimmunization.
- C. ABO incompatibility.
- D. Esophageal varices.
Correct Answer: A
Rationale: Pale stools and jaundice in a neonate suggest biliary atresia, a condition requiring urgent evaluation.
You are the chair person for the healthcare facility's newly formed multidisciplinary Safety Committee. During the Forming stage of this group's development major conflicts have arisen. Which technique of conflict resolution should you use to resolve these conflicts?
- A. Passivity
- B. Compromise
- C. Competition
- D. Accommodating Others
Correct Answer: B
Rationale: During the Forming stage, where group members are establishing relationships, compromise is the most effective conflict resolution technique to promote collaboration and consensus while addressing conflicts constructively.
Which of the following techniques is correct when administering a subcutaneous injection?
- A. Use a 1-inch needle for injection.
- B. Insert the needle at a 45-degree angle to the skin.
- C. Spread the skin tightly at the injection site.
- D. Draw 0.2 mL of air into the syringe before administration.
Correct Answer: B
Rationale: A subcutaneous injection is correctly administered at a 45-degree angle (or 90 degrees for obese patients) using a 5/8-inch needle, pinching the skin, without an air bubble.