Set 3
A nurse is administering medication to a client who asked the nurse to leave the medication at the bedside to to be taken at a later time. Which of the following responses should the nurse make? A. Call me when you are ready, and I will return with the medication. B. Since you were taking this medication at home, I will leave it for you to take. C. I will come back in 30 minutes to check that you took the medication so I can chart the time. D. If you refuse to take the medication now, I can't give it again until your next scheduled time.
A. Call me when you are ready, and I will return with the medication. The nurse is responsible for administering the medication and for following professional standards by adhering to the six rights of medication administration
Play versus caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice Tai chi C. Place a jasmine scented air freshener in the clients room D. Offer the client ginger tea
A. Encourage the client to listen to soft music The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain.
A nurse is preparing to assist an older adult client with ambulation following bed rest for three days. Which of the following actions should the nurse take to decrease the risk of fall? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating C. Instruct the client to sit on the edge of the bed for 15 seconds before ambulating D. Walk to the behind the client during ambulation
A. Use a gait belt during ambulation The nurse should use a gait belt to keep the client center of gravity midline and decrease the risk of a fall
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert a rectal tube 15.2 cm. Or 6 inches B. Wear sterile gloves to insert the tubing C. Position the client on his left side D. Hold the solution bag 91 cm or 36 inches above the clients rectum
C. Position the client on his left side Positioning is an important aspect of administering an enema. Having a client lying on his left side facilitates the flow of the enema solution into the sigmoid and descending colon
A nurse is providing teaching to a group of newly licensed nurses about ways that client require healthcare associated infections. Which of the following route of infection should the Manager identified as in iatrogenic HAI? A. Infection acquired from and proper hand hygiene B. Infection acquired by drug resistance C. Infection acquired by inappropriate waste disposal D. Infection acquired from a diagnostic procedure
D. Infection acquired from a diagnostic procedure I actually genic HAI's directly result from diagnostic or therapeutic procedures
A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysisIncludes the following values: PH of 7.25, PaCO2 of 40, and HCO3 of 18. Which of the following as a base and balances it should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis
D. Metabolic acidosis A pH of 7.25 indicates acidosis. If the causes respiratory, PHNC02 values will deviate in opposite directions. Since the PaCO2 is with an expected reference range, despite the low pH, the cosmos be metabolic. Therefore the nurse should report to the provider that the client has metabolic acidosis.
A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "all his equipment is making me nervous." Which of the following responses should the nurse offer? A. You don't need the equipment for very long B. All of this equipment can be frightening C. Why does the equipment bother you? D. Let me tell you about what each machine does
B. All this equipment can be frightening This statement is therapeutic because the nurse is reflecting the client statement. The client is feeling fearful, and this response shows the nurse understands those feelings which will encourage the client to communicate more.