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Which of these actions by the nurse best prevents medication errors when administering medications to a client?
- A. Checking the client's wristband before giving medications
- B. Using two forms of client identification before administering medication
- C. Administering medications at the exact time they are ordered
- D. Verifying the medication order with another nurse
Correct Answer: B
Rationale: Using two forms of client identification (e.g., name and medical record number) is the best practice to prevent medication errors by ensuring the right client receives the medication.
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The nurse seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. Which of the following labs provides the best indicator for renal function?
- A. urinalysis
- B. creatinine and blood urea nitrogen
- C. chemistry of electrolytes
- D. creatinine clearance
Correct Answer: D
Rationale: Due to decreases in lean body mass, blood creatinine is not as good an indicator of the elderly client's renal function as creatinine clearance. Creatinine clearance is a widely used test for glomerular filtration rate.
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
- A. To observe the type and amount of nasogastric tube drainage
- B. Monitor the client for nausea or other complications
- C. Irrigate the nasogastric tube with the ordered irrigant
- D. Perform nostril and mouth care
Correct Answer: D
Rationale: Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks involve assessment or advanced skills that require a licensed nurse.
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?
- A. 1 foot
- B. 2 feet
- C. 4 feet
- D. 6 feet
Correct Answer: D
Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger.
After an explosion at a factory one of the employees approaches the nurse and says 'I am an unlicensed assistive personnel (UAP) at the local hospital.' Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers?
- A. Get temperatures
- B. Take blood pressure
- C. Palpate pulses
- D. Check alertness
Correct Answer: C
Rationale: Palpate pulses. The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated, those clients would need to be seen first.