Exam 2

The nurse is preparing hydrochlorothiazide 50-mg tablet from unit stock. The health care provider orders 75 mg of hydrochlorothiazide PO for the client's hypertension. How many tablets of hydrochlorothiazide will the nurse administer to the client? A. 1.5 tablets B. 2 tablets C. 0.5 tablet D. 1 tablet

A. 1.5 tablets

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, what temperature range will the nurse set the pad? A. 105°F to 109°F (40.5°C to 43°C) B. 90°F to 99°F (32.2°C to 37.2°C) C. 100°F to 104°F (37.7°C to 40°C) D. 110°F to 115°F (43.3°C to 46.1°C)

A. 105°F to 109°F (40.5°C to 43°C)

Which client is a greatest risk of developing a pressure injury? A. 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness B. 25-year-old client on bed rest for 24 hours following a procedure C. 84-year-old client diagnosed with a urinary tract infection who frequently gets out of bed without calling for assistance D. 17-year-old client postoperative for fracture of the upper extremity

A. 47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness

The nurse needs half of a tablet of medication and is preparing to split the tablet but there is no score. What should the nurse do? Select all that apply. A. Call the health care provider. B. Refrain from splitting the tablet. C. Cut the tablet in half. D. Check with the pharmacy. E. Administer a whole tablet.

A. Call the health care provider. B. Refrain from splitting the tablet.

The nurse is changing the dressing of a client whose skin has been irritated by the frequent removal of adhesive tape that holds the dressing in place. Which would be a recommended nursing intervention? A. Use Montgomery straps instead of adhesive tape to hold the dressing in place. B. Use a skin barrier on the wound itself prior to applying a dressing. C. Cleanse the area with an antimicrobial wipe prior to applying the new dressing. D. Cleanse the area with an alcohol wipe prior to applying the new dressing.

A. Use Montgomery straps instead of adhesive tape to hold the dressing in place.

Which action by the nurse is most appropriate when the sutures are difficult to remove because of crusted dried blood? A. Use a sterile gauze and sterile saline to gently remove the crusted dried blood. B. Use a sterile alcohol prep to soak the sutures until they soften. C. Notify the health care provider of the findings and that the sutures cannot be removed. D. Cut the crusted dried blood off using sterile scissors and tweezers.

A. Use a sterile gauze and sterile saline to gently remove the crusted dried blood.

Which client is most likely to require that the sutures be left in place for an extended period of time? A client who: (SATA) A. has a current history of alcoholism. B. has decreased urine output. C. requires assistance with getting out of bed and ambulation. D. uses the patient-controlled anesthesia (PCA) pump frequently.

A. has a current history of alcoholism.

When applying a warm compress, which client will benefit most from the application of moist heat instead of dry heat? A client who: A. requires that the heat penetrate deeply into the tissues. B. has chronic arthritic joint pain. C. needs relief from muscle tension and occasional spasms. D. has a wound with inflammation.

A. requires that the heat penetrate deeply into the tissues.

Applying a cold therapy

Applying a cold therapy

Applying a warm compress

Applying a warm compress

The client is prescribed digoxin 0.125 mg PO every day. The nurse obtains the medication from unit stock and discovers that digoxin only comes in a 0.25-mg tablet. How many tablets of digoxin should the nurse administer to the client? A. 1.5 tablets B. 0.5 tablet C. 2 tablets D. 1 tablet

B. 0.5 tablet

The nurse is preparing a liquid medication for a client. The health care provider prescribes cimetidine hydrochloride 600 mg PO for gastrointestinal bleeding. The pharmacy sends cimetidine hydrochloride 300 mg/5 mL. How many teaspoons should the nurse administer? A. 1.5 teaspoon B. 2 teaspoons C. 0.5 teaspoon D. 1 teaspoon

B. 2 teaspoons

The nurse is splitting medications. After splitting the tablet and administering half to the client, what should the nurse do with the remaining half? Select all that apply. A. Send medication back to the pharmacy. B. Dispose of medication per hospital protocol. C. If the medication is a narcotic, waste with another nurse present. D. Save medication in client's drawer for next administration. E. Dispose of medication in a toilet.

B. Dispose of medication per hospital protocol. C. If the medication is a narcotic, waste with another nurse present.

What should the nurse do with any surgical staples removed from a surgical incision? A. Save them for the health care provider to observe on rounds. B. Dispose of them in a sharps container. C. Wrap them up in a gauze sponge for disposal. D. Dispose of them in a biohazard bag.

B. Dispose of them in a sharps container.

The nurse enters the client's room to administer oral medications. Which action would the nurse take first? A. Offer the client something to drink. B. Perform hand hygiene. C. Confirm the client's identity. D. Ask the client about any allergies.

B. Perform hand hygiene.

A nurse is preparing several oral medications for administration. One of the medications requires the nurse to obtain the client's apical pulse before administering it. Which action would be most appropriate? A. Giving the medication requiring the assessment at a different time. B. Placing the medication requiring the assessment in a separate medication cup. C. Completing the assessment before preparing the medication in the medication cup. D. Putting all the medications to be given in the same cup.

B. Placing the medication requiring the assessment in a separate medication cup.

After setting up a sterile field and putting on sterile gloves, the nurse prepares to clean a client's surgical wound. Which cleaning technique would the nurse use to prevent contamination of the wound? The nurse cleans the wound from the: A. outside to center using a new gauze for each wipe. B. top to the bottom using a new gauze for each wipe. C. side to side using a new gauze for each wipe. D. distal to proximal using a new gauze for each wipe.

B. top to the bottom using a new gauze for each wipe.

The nurse opens the multidose container of oxycodone. The nurse needs 1.5 tablets to deliver the as needed dose, and the tablets in the container are not scored. What action by the nurse is best? A. Administer one tablet until the issue is resolved. B. Document the medication dose as not administered. C. Call the pharmacy to request a supply change. D. Cut the second tablet in half using a pill splitter.

C. Call the pharmacy to request a supply change.

A nurse is preparing to administer oral medications to a client. While opening the unit dose package, the medication inadvertently falls on the floor. Which action by the nurse would be most appropriate? A. Notify the health care provider that the medication was dropped. B. Call the pharmacy to determine if the medication can be given. C. Discard the current unit-dose package and obtain a new one. D. Document that the client refused the medication.

C. Discard the current unit-dose package and obtain a new one.

When applying an external heating pad, which prescription from the health care provider would the nurse question? A. Maintain the temperature between 105°F to 109°F (40.5°C to 43°C). B. Assess site frequently during application of the heating pad. C. Leave heating pad on for 40 to 45 minutes, then off for 2 hours. D. Use gauze to secure the heating pad to the site of application.

C. Leave heating pad on for 40 to 45 minutes, then off for 2 hours.

When assessing a wound 2 hours after removing the surgical staples, the nurse notes that the wound edges have begun to pull apart. What action should the nurse take next? A. Re-staple the surgical incision. B. Apply a wet to dry saline dressing to the wound area. C. Notify the health care provider that the wound edges are coming apart. D. Call a rapid response.

C. Notify the health care provider that the wound edges are coming apart.

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing? A. To soften the dressing to prevent trauma to the wound bed. B. To prevent the dressing from sticking to the wound. C. To promote moist wound healing and protect the wound from contamination and trauma. D. To fill the wound with saline to dissolve wound secretions.

C. To promote moist wound healing and protect the wound from contamination and trauma.

The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development? A. Keep the head of the bed elevated 35 degrees. B. Gently massage any reddened areas for several minutes. C. Turn and reposition the client every 2 hours. D. Pull the client up in the bed very gently.

C. Turn and reposition the client every 2 hours.

The nurse is changing the dressing on a client's surgical wound and notices that part of the dressing is sticking to the underlying skin. What is the recommended nursing intervention in this situation? A. Soak the area with sterile water using gauze pads. B. Wipe the area with an antimicrobial swab and pull the dressing from the skin. C. Use small amounts of sterile saline to help loosen and remove the dressing. D. Wipe the area with an alcohol wipe and pull the dressing from the skin.

C. Use small amounts of sterile saline to help loosen and remove the dressing.

Cleaning a wound and applying a dressing

Cleaning a wound and applying a dressing

After 30 minutes, the nurse comes to remove the warm compress from a client's wound site. The client requests to leave the warm compress on a little longer. What is the best response by the nurse? A. "Ok, we can leave it on for about 10 more minutes then I will return to remove it." B. "I cannot do that because your health care provider only prescribed it for 30 minutes at a time." C. "Since it is making you feel better, I will call the health care provider and ask to leave it on longer." D. "Leaving it on for more than 30 minutes can cause complications such as tissue injury."

D. "Leaving it on for more than 30 minutes can cause complications such as tissue injury."

The nurse is preparing to administer a sublingual medication. Which instruction to the client is correct? A. "Swallow frequently to get the best benefit." B. "Take a big drink of water and swallow the pill." C. "Chew the pill so it will dissolve faster." D. "Try not to swallow while the pill dissolves."

D. "Try not to swallow while the pill dissolves."

A nurse gives a 13-year-old client an ice bag to place over a sprained ankle. How long should the nurse have the client apply the bag before the nurse removes it? A. 10 minutes B. 15 minutes C. 25 minutes D. 20 minutes

D. 20 minutes

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? A. Apply a skin protectant to the incision site. B. Apply a sterile gauze sponge over the incision site. C. Apply a transparent dressing over the incision site. D. Apply a skin protectant to the skin around the incision.

D. Apply a skin protectant to the skin around the incision.

What action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them? A. Notify the health care provider of the dried blood and wait for a prescription to proceed. B. Apply a warm compress to the surgical staples and allow the dried blood to melt. C. Go ahead and remove the staples as they will pop up and out of the skin. D. Apply moist saline compresses to loosen crusts before attempting to remove the staples.

D. Apply moist saline compresses to loosen crusts before attempting to remove the staples.

The nurse has administered a client's medication. Which action would be most appropriate if the client vomits immediately, or soon after administration? A. Do not re-administer the medication until the next dose is due. B. Check the medication to see if vomiting is indicated. C. Clean up the vomit/emesis and re-administer the medication. D. Check the vomit/emesis for pills or pill fragments and call the client's health care provider.

D. Check the vomit/emesis for pills or pill fragments and call the client's health care provider.

In which client would the application of an external heating pad be contraindicated? A. Client who has a wound that is infected. B. Client who has muscle spasms from tension. C. Client who has chronic arthritic pain. D. Client who has a wound that is bleeding.

D. Client who has a wound that is bleeding.

The nurse is administering routine medications to a postsurgical client and the client asks, "Could I have something for pain?" The nurse checks the medication administration record (MAR) and notes that the medication is an opioid. What should the nurse do? A. Give all the medications together. B. Open the pill into the client's hand. C. Administer the medication and let the client take it when the client wants. D. Place the opioid into a separate cup.

D. Place the opioid into a separate cup.

The client tells the nurse that the medication in the cup is not the same as the medication he took the day before. The client is insistent that the medication is not the one prescribed. Which action by the nurse would be least appropriate? A. Check the drug package with what is written on the medication administration record. B. Contact the health care provider to determine if the medication prescribed is correct. C. Verify what is written on the medication administration record with the client's chart. D. Tell the client that he must take this medication because it is prescribed by the health care provider.

D. Tell the client that he must take this medication because it is prescribed by the health care provider.

Preventing Pressure Injury

Preventing Pressure Injury

Removing Surgical Staples

Removing Surgical Staples

Removing Sutures

Removing Sutures

The nurse is in the client's room to administer the client's morning oral medications. Which action should the nurse take first? A. Confirm the client's identity. B. Open the unit-dose packages of medications. C. Pour a cup of water for the client to drink. D. Document the medications being given.

A. Confirm the client's identity.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? A. Discontinue the therapy and assess the client. B. Document the findings in the client's medical record. C. Notify the health care provider of the findings. D. Gently rub and massage the area to warm it up.

A. Discontinue the therapy and assess the client.

The nurse is administering a client's medication and more tablets than needed fall into the bottle cap. What should the nurse do? A. Drop extra tablets into bottle from bottle cap. B. Put the extra tablets into a specialty disposal unit. C. Drop the extra tablets down the sink. D. Throw the extra tablets away.

A. Drop extra tablets into bottle from bottle cap.

The nurse is teaching a client the purpose of using an external heating pad. What should the nurse include in the teaching plan? Select all that apply. A. It helps to relieve pain from arthritis and joint stiffness. B. It reduces the discomfort of muscle tension and muscle spasms. C. It promotes healing by accelerating the body's natural inflammatory response. D. It promotes healing by decreasing perfusion to the site and decreasing edema. E. It can be used to treat inflammation, chronic pain, and surgical wounds.

A. It helps to relieve pain from arthritis and joint stiffness. B. It reduces the discomfort of muscle tension and muscle spasms. C. It promotes healing by accelerating the body's natural inflammatory response. E. It can be used to treat inflammation, chronic pain, and surgical wounds.

The nurse is preparing to split medication for client administration. What method should the nurse use to split the medication? A. Place the pill in the pill splitter and close. B. Place the pill in the pill grinder and twist closed. C. Divide the pill using a knife. D. Split the pill by hand, wearing gloves.

A. Place the pill in the pill splitter and close.

A nurse is distributing the 0900 medications to the client. What should the nurse do when removing a tablet from a multi-dose bottle? Select all that apply. A. Put an extra tablet back into the bottle from cap. B. Take the multi-dose bottle into the client's room. C. Touch the tablet(s) with the fingers. D. Use gloves for extra protection. E. Pick up two tablets directly from the bottle.

A. Put an extra tablet back into the bottle from cap. B. Take the multi-dose bottle into the client's room. D. Use gloves for extra protection.

The nurse is preparing to perform wound care. Which intervention should be implemented to protect the nurse from injury? A. Raise the bed to elbow height. B. Position the client. C. Gather all necessary equipment. D. Maintain a sterile field.

A. Raise the bed to elbow height.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? A. Reduce the time interval between dressing changes. B. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. C. Assure that the packing material is completely saturated when placed in the wound. D. Use less packing material

A. Reduce the time interval between dressing changes.

The nurse is explaining the benefits of cold therapy to a client. What should the nurse include in the teaching plan? Select all that apply. A. Reduces bleeding and hematoma formation B. Causes blood vessels to dilate C. Increases perfusion to the wound site D. Slows the transmission of pain stimuli E. Reduces swelling and inflammation

A. Reduces bleeding and hematoma formation D. Slows the transmission of pain stimuli E. Reduces swelling and inflammation

The nurse administers the client's scheduled morning medications. The previous dose of antihypertensive was held due to a blood pressure that was too low according the health care provider's parameters. What does the nurse do with this scheduled unit-dose packaged antihypertensive medication? A. Set the antihypertensive dose aside pending assessment. B. Ask the client to report any dizziness and lightheadedness. C. Teach the client to use the call bell whenever getting out of bed. D. Place the dose in the medication cup with other medications.

A. Set the antihypertensive dose aside pending assessment.

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply. A. Skin around injury is red and warm to touch B. Visible subcutaneous fat C. Drainage is foul smelling and green in color D. Full-thickness tissue loss E. No bone, tendon, or muscle visible.

A. Skin around injury is red and warm to touch B. Visible subcutaneous fat D. Full-thickness tissue loss E. No bone, tendon, or muscle visible.

When administering medications to a client, what information should the nurse know about the medication? Select all that apply. A. safe dose range B. purpose C. cost D. action E. adverse effects

A. safe dose range B. purpose D. action E. adverse effects

A nurse is measuring a liquid medication in a graduated liquid medication cup. The nurse determines the correct amount by reading: A. the bottom of the meniscus. B. the top of the amount line on the cup. C. on both sides of the amount line. D. just below the line for the amount.

A. the bottom of the meniscus.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? A. to splint the area when engaging in activity B. to turn the head away from the area whenever they cough C. to remain in bed for the next 4 hours D. to ambulate using a cane or walker

A. to splint the area when engaging in activity

Administering oral medications

Administering oral medications

Applying an external heating pad

Applying an external heating pad

Which client would be at greatest risk for developing a pressure injury? A. Client who is delirious after taking pain medications B. Adult client who is comatose C. Older adult client who has chronic obstructive pulmonary disease (COPD) D. Adolescent client with a cast on the left leg

B. Adult client who is comatose

Which clients will the nurse recognize are at an increased risk of thermal injury when using an external heating pad? Select all that apply. A. Client who is experiencing joint pain. B. Client who has a spinal cord injury. C. Client who has diabetes. D. Client who has peripheral neuropathy. E. Client who is an older adult.

B. Client who has a spinal cord injury. C. Client who has diabetes. D. Client who has peripheral neuropathy. E. Client who is an older adult.

The nurse is planning to replace a client's wound dressing. The deep wound bed is to remain moist and requires packing. Which action is appropriate? A. Insert rolled gauze into the wound; saturate it with povidone-iodine solution and cover with a moisture-impervious dressing. B. Loosely pack the dampened dressing material to prevent too much pressure on the wound bed. C. Instill 50 mL of normal saline into the wound and loosely cover with packing material. D. Fill the wound with sterile saline gel and cover with a large transparent dressing.

B. Loosely pack the dampened dressing material to prevent too much pressure on the wound bed.

When pouring a liquid medication into a graduated liquid medication cup, which nursing action would be most appropriate? A. Position the cup at an angle to the mouth of the liquid. B. Place the cup on a flat surface at eye level. C. Hold the cup in the nondominant hand above waist level. D. Hold the cup directly against the lip of the liquid container.

B. Place the cup on a flat surface at eye level.

What action will the nurse take to ensure a wound is ready for the sutures to be removed? A. Apply gentle pressure to the incision and observe for dehiscence. B. Remove every other suture and assess the wound edges. C. Review the number of days the sutures have been in place. D. Apply sterile saline to the suture site and assess the wound edges.

B. Remove every other suture

To assess for circulatory compromise, what assessments will the nurse perform at the site of application before applying a warm compress? Select all that apply. A. Respiratory rate B. Skin color C. Presence of sensation D. Evidence of edema E. Distal pulses

B. Skin color C. Presence of sensation D. Evidence of edema E. Distal pulses

The nurse splits a medication for client administration. What should the nurse do to assure safety and proper documentation? Select all that apply. A. Take the client's entire medication drawer to bedside. B. Take computer to the bedside. C. Take medication to bedside. D. Take health care provider's prescription to the bedside. E. Take medication package and label to bedside.

B. Take computer to the bedside. C. Take medication to bedside. E. Take medication package and label to bedside.

The nurse is preparing to clean a client's surgical wound. What would the nurse assess before beginning the procedure? A. Any physical limitations the client may have B. The client's comfort and effectiveness of pain medication C. The client's temperature and pulses D. Color of drainage on the wound dressings

B. The client's comfort and effectiveness of pain medication

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound: A. has redness with partial thickness loss of dermis. B. has black brown eschar covering the top. C. has bright red granulation tissue in the wound bed. D. has exposed bone, tendon, or muscle visible.

B. has black brown eschar covering the top.

Which question by the nurse, to the client, will best help evaluate the outcome of having applied cold therapy? A. "Have you noticed any increase in the wound drainage?" B. "Can I help you get up to the chair now?" C. "Do you feel your muscle spasms have decreased?" D. "Does your dressing feel like it is too tight?"

C. "Do you feel your muscle spasms have decreased?"

The nurse is removing the dressing from an abdominal surgical wound during wound care and notices that the wound edges are not intact, there are multiple staples on the dressing, and the surrounding tissue is red with purulent drainage. The chart reports that the incision was clean and dry with the approximated edges and staples intact upon the last assessment. What would be the first recommended nursing intervention in this situation? A. Leave the wound open and notify the health care provider. B. Tell the client that this is a life-threatening situation and that the health care provider will be called. C. Assess for pain, shortness of breath, and abdominal pressure. D. Place the client in a sitting position to reduce pressure on the abdomen.

C. Assess for pain, shortness of breath, and abdominal pressure.

The nurse is performing the third medication check for a medication administered from a multi-dose bottle. What should the nurse do? A. Take the tablet out of the bottle and identify it visually. B. Check the client's identification after administration of the medication. C. Check the multi-dose bottle label after identifying the client and before administering the medication. D. Compare the medication label on the bottle to the medication administration record (MAR).

C. Check the multi-dose bottle label after identifying the client and before administering the medication.

After reviewing the skills for administering different medications, a student nurse demonstrates the need for additional review when she does takes which action? A. Takes the medication instead of leaving it at the client's bedside. B. Documents in the MAR that the medication was taken by the client. C. Leaves before verifying that the client has swallowed the medication. D. Asks the client if he or she would like the medication in a cup or in the hand.

C. Leaves before verifying that the client has swallowed the medication.

Which route of medication administration is most commonly prescribed? A. Subcutaneous B. Topical C. Oral D. Intravenous

C. Oral

The nurse is distributing afternoon medications to the clients. When removing a tablet from a multi-dose bottle, what should the nurse do first? A. Pick a tablet out of the bottle with the fingers. B. Drop tablet into a medication cup. C. Pour the tablet into the bottle cap. D. Shake a tablet out onto the hand.

C. Pour the tablet into the bottle cap.

The nurse is changing the dressing on a client's surgical wound. After the old dressing is removed, the nurse notices that the client's skin is red and blistered where the dressing had been secured with tape. Which would be an appropriate action by the nurse? A. Notify the health care provider for further instructions. B. Allow the wound to air dry. C. Replace the dressing with a larger one. D. Replace the dressing with a smaller one.

C. Replace the dressing with a larger one.

When assessing the area of application of a warm compress, the nurse observes skin maceration of the surrounding area, and the client reports increased discomfort. What should the nurse do first? A. Document the event in the client's medical record. B. Notify the health care provider of the client's report of increased discomfort. C. Stop the heat application and completely remove the compress. D. Administer the prescribed PRN analgesic.

C. Stop the heat application and completely remove the compress.

The nurse is teaching a client how to prepare and administer liquid medications. The client has been on other types of medications for several years. What common error would be most appropriate for the nurse to include in teaching this client? A. An oral syringe is the only way to administer liquid medications. B. If the measurement is a little incorrect, it is not a problem. C. The client can use any type of measuring device. D. When sharing medication with others, they should take the same dose

C. The client can use any type of measuring device.

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding? A. Stage 1 pressure injury B. Stage 2 pressure injury C. Unstageable, skin intact D. Deep tissue injury

D. Deep tissue injury

When removing a client's surgical wound dressing, the nurse notes that there is wound separation and rupture. What is the term for this wound complication? A. Undermining. B. Ecchymosis. C. Sinus tract. D. Dehiscence.

D. Dehiscence.

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse? A. Leave the therapy on for 10 more minutes and return to remove it after that time. B. Explain to the client that this is not possible because of the health care provider's prescription. C. Assist the client to get out of bed and sit up in a chair for a short while. D. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.

D. Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis.

The instructor observes a nursing student who is preparing a liquid medication from a multi-dose bottle. Which action would concern the instructor if it were demonstrated by the student? A. Wipes the lip of the container with a paper towel after pouring the liquid. B. Compares the label on the bottle with the medication administration record. C. Measures the liquid in the cup using the bottom of the meniscus at eye level. D. Holds the bottle of liquid medication with the label facing the medication cup.

D. Holds the bottle of liquid medication with the label facing the medication cup.

The nurse prepares the client's nightly medication doses and needs to administer an as needed dose of a hypnotic medication for sleep. The sleep medication is in a unit-dose package. What action does the nurse take? A. Place the medication in the cup with the scheduled night medications. B. Assess the client's blood pressure before administering the dose. C. Document the client's pain scale score between 0 and 10. D. Open the package after the client confirms the dose is wanted.

D. Open the package after the client confirms the dose is wanted.

The nurse has finished cleaning a client's surgical wound. What would be the nurse's next action in this procedure? A. Position the client to promote drainage of the solution. B. Allow the wound to air dry for 2 minutes. C. Measure the length, depth, and width of the wound. D. Pat the wound dry with a sterile gauze sponge.

D. Pat the wound dry with a sterile gauze sponge.

The nurse assesses the surgical dressing of a client who has just arrived from the post-anesthesia care unit (PACU) and observes the dressing has a moderate area of serous drainage on it. What is the best action by the nurse? A. Call a rapid response and stay with the client B. Change the dressing using sterile technique C. Notify the health care provider of the bleeding D. Reinforce the dressing and assess site frequently

D. Reinforce the dressing and assess site frequently

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding? A. Deep tissue injury B. Unstageable, skin intact C. Stage 2 pressure injury D. Stage 1 pressure injury

D. Stage 1 pressure injury

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time? A. Prescribe the client a high carbohydrate diet to promote healing. B. Remove the eschar by irrigating with sterile saline. C. Teach the client to reposition every 4 hours. D. Teach the client ways to relieve the pressure on the heel.

D. Teach the client ways to relieve the pressure on the heel.