Question

A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

Answer 1

Correct Answers:

Determine if the client has a support system.

Rationale :

♦️ The first step in addressing ineffective coping is to assess whether the client has a support system to help manage the stress of a chronic condition.

♦️ Knowing if family, friends, or community resources are available provides insight into the client’s coping resources.

♦️ Scheduling mental health consults or providing coping information are important but should come after assessment.

♦️ Encouraging support group attendance is beneficial but depends on client readiness and available support.

♦️ Prioritizing assessment aligns with nursing process principles to provide individualized care.

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Answer 2

Correct Answers:

Determine if the client has a support system.

Rationale :

✔️ This question repeats Q1, emphasizing the importance of assessing the client's support system first.

✔️ Understanding the social support available helps tailor further interventions effectively.

✔️ Mental health referrals and education are subsequent steps based on this initial assessment.

✔️ Encouragement for support group participation is more effective once the client’s network and preferences are known.

✔️ Proper sequencing enhances care outcomes and patient engagement.

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Answer 3

Correct Answers:

Use a filter needle to aspirate the medication.

Rationale :

● Filter needles are used to remove glass particles that might enter the medication solution when breaking an ampule.

● Air should not be injected into the ampule as it is a sealed container; injecting air is only for vials.

● Adding diluent depends on medication preparation instructions and is not routine for all ampules.

● Cleaning the ampule tip after opening is unnecessary as the ampule is sterile inside and breaking the neck exposes sterile medication.

● Using filter needles enhances patient safety by preventing particulate contamination.

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Answer 4

Correct Answers:

Play music in the client's room.

Rationale :

◈ Playing music is a nonpharmacological intervention that can help distract the client from pain and promote relaxation.

◈ Keeping the room well lit may stimulate the client and disrupt rest, which can worsen pain perception.

◈ A cool room may increase discomfort or muscle tension in some clients.

◈ Encouraging abstaining from distractions is counterproductive to pain management.

◈ Nonpharmacological interventions like music complement medication and improve holistic care.

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Answer 5

Correct Answers:

Syringe

Rationale :

⬛ A syringe is used to irrigate a stage 4 pressure injury, helping to cleanse the wound and remove debris or exudate.

⬛ Cotton-tipped applicators and tongue depressors are for smaller or superficial wounds, not deep stage 4 ulcers.

⬛ Adhesive tape is used for securing dressings but is not a wound cleansing tool.

⬛ Proper wound irrigation supports healing and reduces infection risk in deep wounds.

⬛ Using the correct supplies ensures effective and safe wound care.

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Answer 6

Correct Answers:

Observe the client's skin integrity every 2 hr.
Ensure that 2 fingers can be placed between the restraint and the client.
Pad bony prominences before applying a restraint.

Rationale :

⏹️ Observe the client's skin integrity every 2 hr

◼️ Frequent skin assessments help prevent skin breakdown and pressure injuries caused by restraints.

◼️ Early identification of skin irritation or damage allows timely intervention.

◼️ This is a standard safety measure in restraint care.

⏹️Ensure that 2 fingers can be placed between the restraint and the client

◼️ This ensures the restraint is secured but not too tight, preventing impaired circulation or injury.

◼️ Proper fit allows for some movement and reduces risk of nerve damage.

◼️ Regular checks are needed to maintain this standard.

⏹️ Pad bony prominences before applying a restraint

◼️ Padding protects skin and tissues over bony areas from pressure and friction.

◼️ This measure decreases the risk of pressure ulcers.

◼️ It enhances client comfort and safety while restrained.

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Answer 7

Correct Answers:

A client receives burns from a heating pad.
A client becomes disoriented and falls out of bed.
A client's visitor becomes dizzy and faints in the client's room.

Rationale :

🟢A client receives burns from a heating pad

✓ This event is a patient safety incident involving injury directly related to care.

✓ Burns from medical devices require documentation to ensure appropriate treatment and prevent future occurrences.

✓ Reporting helps the facility investigate causes and implement corrective measures.

🟢A client becomes disoriented and falls out of bed

✓ Patient falls are considered serious adverse events that pose significant risk for injury or complications.

✓ Documenting falls allows healthcare teams to perform root cause analyses and improve safety protocols.

✓ Falls also often trigger immediate reassessment of the client’s condition and environment.

🟢A client's visitor becomes dizzy and faints in the client's room

✓ Although not a patient, visitors experiencing adverse events on hospital premises must be reported for liability and safety reasons.

✓ Documentation ensures appropriate medical evaluation and follow-up for the visitor.

✓ It also supports institutional safety policies and prevents future incidents.

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Answer 8

Correct Answers:

Providing postmortem care for a client who has just died

Rationale :

◼️ Postmortem care is a non-invasive task appropriate to delegate to assistive personnel (AP) as it involves hygiene and positioning after death.

◼️ Administering vaginal cream, suctioning a tracheostomy, and changing IV dressings require licensed nursing skills and assessment.

◼️ Delegation ensures client safety while optimizing nursing workload.

◼️ Proper delegation supports team efficiency and quality care delivery.

◼️ Nurses retain accountability for overall client outcomes.

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Answer 9

Correct Answers:

A. Ensure the oxygen delivery system is at least 8 feet from any heat source B. C. D. E. F. G.
Take antibiotic medication with or without food.
Take antibiotics for 10 days.
Store the oxygen cylinder wrench with the oxygen tank.
Take steroid medication in the morning.

Rationale :

✔️Ensure the oxygen delivery system is at least 8 feet from any heat source

✓ Oxygen supports combustion and must be kept away from heat sources to prevent fires.

✓ Patient and caregiver safety depends on proper oxygen storage and use.

✔️Take antibiotic medication with or without food

✓ Most antibiotics can be taken without food unless specified; adherence to schedule is key for effectiveness.

✓ This instruction prevents confusion and promotes compliance.

✔️Take antibiotics for 10 days

✓ Completing the full antibiotic course is essential to eradicate infection and prevent resistance.

✓ Premature discontinuation can cause treatment failure.

✔️Store the oxygen cylinder wrench with the oxygen tank

✓ The wrench is necessary for emergency shut-off and must be readily accessible.

✓ This supports safety protocols.

✔️Take steroid medication in the morning

✓ Taking steroids in the morning aligns with the body’s natural cortisol rhythm, reducing side effects.

✓ It helps improve medication tolerance and effectiveness.

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Answer 10

Correct Answers:

"I will use disinfectant to clean the blood pressure cuff after use on a client."

Rationale :

● Blood pressure cuffs can be a vector for pathogen transmission and must be cleaned with disinfectant between clients.

● Rinsing contaminants with hot water alone is inadequate for infection control.

● Sterile gloves are not needed for routine bathing, even if the client is incontinent.

● Double-bagging linens daily is unnecessary unless linens are visibly contaminated with infectious material.

● Proper cleaning of reusable equipment prevents healthcare-associated infections.

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QLexNursing

1 :
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

2 :
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

3 :
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

4 :
A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take.

5 :
A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

6 :
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

7 :
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

8 :
A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

9 :
The nurse is reinforcing discharge teaching with the client and their caregiver.

Answer Options

10 :
A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

QLexNursing

1 : A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

2 : A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

3 : A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

4 : A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take.

5 : A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

6 : A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

7 : A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

8 : A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

9 : The nurse is reinforcing discharge teaching with the client and their caregiver.

Answer Options

10 : A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

1 :
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

2 :
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

3 :
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

4 :
A nurse is providing nonpharmacological interventions for a client who is experiencing pain. Which of the following actions should the nurse take.

5 :
A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

6 :
A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

7 :
A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.)

8 :
A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

9 :
The nurse is reinforcing discharge teaching with the client and their caregiver.

10 :
A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?