Nokea
While the nurse is preparing medications, a code occurs. One of the nursing assistants offers to help by administering the medications. What is the best response by the nurse?
- A. Allow the nursing assistant to give the medications
- B. Hold the medications until after the code
- C. Give the medications and then help with the code
- D. Ask the nursing assistant when she was checked off on giving medications
Correct Answer: B
Rationale: Holding medications prioritizes the code response, as CNAs cannot administer medications, ensuring patient safety and appropriate task delegation.
You may also like to solve these questions
An infant is to be admitted with severe diarrhea. Which room assignment is best for this infant?
- A. A private room
- B. A room close to the nurse's station
- C. A room with a 2-year-old child who has a broken leg
- D. A room with another infant with severe diarrhea
Correct Answer: A
Rationale: A private room prevents transmission of infectious diarrhea to others. Proximity to the station, sharing with a non-infectious patient, or another diarrheal infant increases risks.
During the admission bath, the nurse notes a region of impaired skin under a large sacral dressing. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Discusses the client's need for a nutrient-rich, high-calorie diet with the dietician
- B. Documents the impaired skin as an unstageable pressure injury in the client's medical record
- C. Gently cleanses the impaired skin with normal saline and pats the area dry with gauze
- D. Places a hydrophilic dressing over the impaired skin after performing wound care
- E. Repositions the client frequently and avoids putting pressure on the impaired skin
Correct Answer: A,C,D,E
Rationale: A nutrient-rich diet (A) supports wound healing. Cleansing with saline (C) prevents infection. A hydrophilic dressing (D) promotes a moist healing environment. Frequent repositioning (E) reduces pressure on the impaired skin.
The nurse is collecting data from a client with heart failure. The nurse notes that the client is agitated, has crackles bilaterally, and is reporting dyspnea and anxiety. The nurse should place the client in
- A. modified Trendelenburg position
- B. high Fowler position
- C. left Sims position
- D. supine position
Correct Answer: B
Rationale: High Fowler position optimizes lung expansion and reduces preload, alleviating dyspnea and crackles in acute heart failure exacerbation.
The nurse is discussing preventive health care with a group of women. Which woman should the nurse advise to have a mammogram?
- A. A 20-year-old who says her breasts hurt before her period
- B. A 25-year-old who was hit in the breast area by a ball
- C. A 32-year-old who has been breastfeeding for 12 months
- D. A 52-year-old who has no breast symptoms
Correct Answer: D
Rationale: Mammograms are recommended starting at age 50 for asymptomatic women per standard guidelines, making the 52-year-old the priority.
The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?
- A. I need to avoid caffeinated products.
- B. I need to get my blood drug levels checked periodically.
- C. I need to report anorexia and sleeplessness.
- D. I take cimetidine rather than omeprazole for heartburn.
Correct Answer: D
Rationale: Cimetidine inhibits theophylline metabolism, increasing toxicity risk. Omeprazole is safer, and this statement indicates a need for further teaching.