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... [Show More] GRADED A+
A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?
A. Place a pillow under the client's knees.
B. Position a trochanter roll under each of the client's hips.
C. Advise the client to wear rubber-soled slippers.
D. Apply an ankle-foot orthotic device to the client's feet. -
ANSWER-D. Apply an ankle-foot orthotic device to the client's feet.
RATIONALE- (The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.)
A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?
A. A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse.
B. A nurse asks a nurse from another unit to assist with documentation for a client.
C. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care.
D. A nurse discusses a client's status with the physical therapist who is caring for the client. - ANSWER-B. A nurse asks a nurse from another unit to assist with documentation for a client.
RATIONALE- (Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.)
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
A. Gently shake the container of medication prior to administration.
B. Transfer the medication to a medicine cup.
C. Place the client in a semi-Fowler's position prior to medication administration.
D. Verify the dosage by measuring the liquid before administering it. - ANSWER-A. Gently shake the container of medication prior to administration.
RATIONALE-(The nurse should gently shake the liquid medication to ensure that the medication is mixed.)
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
A. Seal unused medications from the facility in a plastic bag.
B. Evaluate the client's ability to self-administer medications.
C. Report an identified discrepancy to The Joint Commission.
D. Compare prescriptions with medications the client received while at the facility. - ANSWER-D. Compare prescriptions with medications the client received while at the facility.
RATIONALE-(When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.)
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
A. "What could I have done to deserve this illness?"
B. "I blame medical science for not curing me."
C. "Where is my daughter at a time like this?"
D. "Will I ever begin to feel in charge of my life again?" -
ANSWER-A. "What could I have done to deserve this illness?"
RATIONALE- (The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.)
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A. Inject 5 units of air into the bottle of regular insulin.
B. Withdraw the correct does of NPH insulin from the bottle.
C. Inject 10 units of air into the bottle of NPH insulin. [Show Less]