Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take?
A. Show the assistive personnel where to apply the medication.
Show the assistive personnel where to apply the medication: This action is not appropriate because only licensed healthcare providers, such as nurses, are allowed to administermedications.
B. Ask the client when the previous nurse last applied the medication.
Ask the client when the previous nurse last applied the medication: While communication with the client is important, it is not a reliable method to verify medication administration accuracy.
C. Identify the client by comparing the medication administration record with the client's room number.
Identify the client by comparing the medication administration record with the client's room number: This action is insufficient to verify the correct client because there could be multiple clients with the same medication due.
D. Compare the label of the medication container with the medication administration record three times.
Compare the label of the medication container with the medication administration record three times: Correct. This action is known as the "three checks" and is an essential step in medication administration. The nurse should compare the medication label with the medication administration record before removing the medication, after removing the medication, and at the bedside before administering the medication.
This question is an excerpt from Nurse Dive's nursing test bank - LPN ATI fundamental proctored exam. Take the full exam now
Full Explanation
A. Show the assistive personnel where to apply the medication: This action is not appropriate because only licensed healthcare providers, such as nurses, are allowed to administer
medications.
B. Ask the client when the previous nurse last applied the medication: While communication with the client is important, it is not a reliable method to verify medication administration accuracy.
C. Identify the client by comparing the medication administration record with the client's room number: This action is insufficient to verify the correct client because there could be multiple clients with the same medication due.
D. Compare the label of the medication container with the medication administration record three times: Correct. This action is known as the "three checks" and is an essential step in medication administration. The nurse should compare the medication label with the medication administration record before removing the medication, after removing the medication, and at the bedside before administering the medication.
Similar Questions
A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?
A. Provide an artificial voice box.
Provide an artificial voice box: An artificial voice box, such as a speech-generating device, is more appropriate for clients who have lost their ability to speak due to laryngeal surgery or other conditions that affect vocal cord function, not aphasia.
B. Avoid using facial gestures.
Avoid using facial gestures: Correct. Clients with aphasia have difficulty understanding and expressing language. Nonverbal communication, including facial gestures, can help convey meaning and support communication with the client.
C. Speak to the client in a louder voice.
Speak to the client in a louder voice: Raising the volume of speech is not the most effective way to communicate with clients with aphasia. It is essential to speak clearly and at a normal volume, as loud speech may lead to misunderstanding or agitation.
D. Ask the client close-ended questions.
Ask the client close-ended questions: While open-ended questions might be challenging for clients with aphasia to answer, closed-ended questions that require only simple responses may not fully address their needs for self-expression and understanding. Using visual cues and gestures can be helpful.
Full Explanation
A. Provide an artificial voice box - This is not typically used for clients with aphasia as it does not address the communication barriers they face.
B. Avoid using facial gestures - Facial gestures can be a helpful non-verbal communication tool, especially for clients with aphasia, so avoiding them is not beneficial.
C. Speak to the client in a louder voice - Aphasia affects language processing, not hearing, so increasing volume does not aid in understanding.
D. Ask the client close-ended questions - This allows the client to respond with 'yes' or 'no', or other simple answers, which can be easier for someone with aphasia.
A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include?
A. Alarm clock that shakes the bed
Alarm clock that shakes the bed: While a vibrating alarm clock can be helpful for waking a person with hearing loss, it may not be a priority modification for safety in the home environment.
B. Flashing smoke alarm
Flashing smoke alarm: Correct. A flashing smoke alarm is a priority modification because it addresses the safety concern of alerting the client in the event of a fire or smoke in the home. The flashing light serves as an effective visual cue to notify the client about the danger.
C. Lowpitched buzzer doorbell
Lowpitched buzzer doorbell: A lowpitched buzzer doorbell can be beneficial for individuals with hearing loss, but it is not as critical as having a flashing smoke alarm for immediate safety.
D. Telephone with an amplified receiver
Telephone with an amplified receiver: An amplified telephone receiver can improve communication for clients with hearing loss but is not as essential for immediate safety as a flashing smoke alarm.
Full Explanation
A. Alarm clock that shakes the bed: While a vibrating alarm clock can be helpful for waking a person with hearing loss, it may not be a priority modification for safety in the home environment.
B. Flashing smoke alarm: Correct. A flashing smoke alarm is a priority modification because it addresses the safety concern of alerting the client in the event of a fire or smoke in the home. The flashing light serves as an effective visual cue to notify the client about the danger.
C. Lowpitched buzzer doorbell: A lowpitched buzzer doorbell can be beneficial for individuals with hearing loss, but it is not as critical as having a flashing smoke alarm for immediate safety.
D. Telephone with an amplified receiver: An amplified telephone receiver can improve communication for clients with hearing loss but is not as essential for immediate safety as a flashing smoke alarm.
A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?
A. "This can help prevent nausea."
"This can help prevent nausea." Turning, coughing, and deep breathing exercises are not primarily aimed at preventing nausea. These exercises are designed to maintain lung function and prevent respiratory complications.
B. "This can help prevent pneumonia."
"This can help prevent pneumonia." Correct. Turning, coughing, and deep breathing exercises are essential postoperative activities that help prevent the development of pneumonia by promoting lung expansion, clearing mucus, and preventing atelectasis.
C. "I should do this every 4 hours."
"I should do this every 4 hours." The frequency of turning, coughing, and deep breathing exercises may vary based on individual client needs and surgical procedures. This statement does not demonstrate a specific understanding of the appropriate timing for these exercises.
D. "I should do this to keep my heart from beating too fast."
"I should do this to keep my heart from beating too fast." Turning, coughing, and deep breathing exercises are not directly related to heart rate regulation. They are focused on lung expansion and airway clearance.
Full Explanation
A. "This can help prevent nausea." Turning, coughing, and deep breathing exercises are not primarily aimed at preventing nausea. These exercises are designed to maintain lung function and prevent respiratory complications.
B. "This can help prevent pneumonia." Correct. Turning, coughing, and deep breathing exercises are essential postoperative activities that help prevent the development of pneumonia by promoting lung expansion, clearing mucus, and preventing atelectasis.
C. "I should do this every 4 hours." The frequency of turning, coughing, and deep breathing exercises may vary based on individual client needs and surgical procedures. This statement does not demonstrate a specific understanding of the appropriate timing for these exercises.
D. "I should do this to keep my heart from beating too fast." Turning, coughing, and deep breathing exercises are not directly related to heart rate regulation. They are focused on lung expansion and airway clearance.