Nokea
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?
- A. Stop suctioning until the pulse oximeter reading is above 95%.
- B. Reposition the pulse oximeter clip to obtain a new reading.
- C. Complete the intermittent suction of the nasopharynx.
- D. Apply an oxygen mask over the client's nose and mouth.
Correct Answer: B
Rationale: Repositioning ensures accurate saturation readings.
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The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?
- A. Keep the medication and see if the client will want to take it later.
- B. Credit the medication back and put it in the client's medication box.
- C. Explain that since the medication is a controlled substance it must be taken.
- D. Have another nurse watch the disposal of the medication into the disposal container.
Correct Answer: D
Rationale: Witnessed disposal ensures safety and compliance.
The healthcare provider prescribes cefixime oral suspension 200 mg by mouth twice a day for an older adult who has difficulty swallowing pills. The bottle is labeled, 'Cefixime for Oral Suspension, USP 100 mg per 5 mL.' How many mL should the nurse administer daily? (Enter numerical value only.)
Correct Answer: 20
Rationale: 200 mg/dose × 2 doses = 400 mg/day; 400 mg ÷ (100 mg/5 mL) = 20 mL/day.
After a seven-day treatment with an IV antibiotic, the healthcare provider discharges a client from the hospital and writes a prescription for an oral antibiotic. While providing discharge instructions, the nurse notes that the dosage for the oral antibiotic is significantly higher than the IV antibiotic. Which resource should the nurse use first in resolving the situation?
- A. Hospital pharmacist.
- B. Healthcare provider.
- C. Medication reference guide.
- D. Nursing unit charge nurse.
Correct Answer: B
Rationale: Provider clarifies prescription accuracy.
The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?
- A. Use firm pressure to pass the tube through the glottis.
- B. Have the client tilt head backward to open the passage.
- C. Give the client a few sips of water to drink.
- D. Remove the tube and attempt reinsertion.
Correct Answer: D
Rationale: Removing and reinserting prevents discomfort and harm.
During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Send a list of medication allergies to the pharmacy.
- B. Secure an allergy bracelet around the client's wrist.
- C. Notify the dietary department of the client's fruit allergy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: B
Rationale: Allergy bracelet ensures immediate awareness.