Nokea
Which of the following is not considered one of the 'Ten Rights of Medication Administration'?
- A. The 'right' verification
- B. The 'right' to refuse
- C. The 'right' documentation
- D. The 'right' client education
Correct Answer: A
Rationale: The Ten Rights of Medication Administration include right patient, drug, dose, route, time, documentation, reason, response, refusal, and education. 'Right verification' is not a standard right.
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The nurse has finished suctioning the tracheostomy of a client. Which parameter should the nurse monitor to determine the effectiveness of the procedure?
- A. Breath sounds
- B. Capillary refill
- C. Respiratory rate
- D. Oxygen saturation level
Correct Answer: A
Rationale: After suctioning a client either with or without an artificial airway, the breath sounds are auscultated to determine the extent to which the airways have been cleared of respiratory secretions. The other assessment items are not as precise as breath sounds for this purpose.
A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should monitor the client for which of the following electrolyte imbalances? Select all that apply.
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypophosphatemia.
- D. Hypermagnesemia.
- E. Hypocalcemia.
Correct Answer: A, C
Rationale: Diabetic ketoacidosis can cause hypokalemia (insulin shifts potassium) and hypophosphatemia (osmotic diuresis).
The nurse monitors the client for a hypoglycemic reaction, knowing that NPH insulin peaks in approximately how many hours following administration?
- A. 1 hour
- B. 2 to 3 hours
- C. 4 to 12 hours
- D. 16 to 24 hours
Correct Answer: C
Rationale: NPH is an intermediate-acting insulin with a peak time in 4 to 12 hours. The remaining options describe periods of time that are either too short or too long.
A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
- A. You are very quiet today.
- B. What are your feelings right now?
- C. Why don't you feel like getting up?
- D. Tell me more about your difficulty with sleeping at night.
Correct Answer: C
Rationale: When a 'why' question is made to the client, an explanation for feelings and behaviors is requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the LPN is using the therapeutic communication technique of acknowledging the client's behavior. In option 2, the LPN is encouraging identification of emotions or feelings. In option 4, the LPN is using the therapeutic communication technique of exploring, which is asking the client to describe something in more detail or to discuss it more fully.
A client with a history of chronic kidney disease is prescribed sodium polystyrene sulfonate (Kayexalate). The nurse should explain that this medication works by:
- A. Reducing blood pressure.
- B. Binding potassium in the gut.
- C. Increasing urine output.
- D. Decreasing blood glucose.
Correct Answer: B
Rationale: Sodium polystyrene sulfonate binds potassium in the gut, reducing serum potassium levels in chronic kidney disease.