Question

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Answer 1

Correct Answers:

Ask the client's full name and date of birth.

Rationale :

✨ The nurse should use at least two approved client identifiers before administering any medication.

✨ Asking the client to state their full name and date of birth provides two reliable identifiers that can be compared with the identification band and MAR.

✨ The nurse should ask an open-ended question rather than saying the client’s name and asking for confirmation.

✨ This method helps prevent wrong-client medication errors, especially when clients have similar names or appearances.

✨ The nurse should complete this verification immediately before administration and follow any additional barcode-scanning requirements in facility policy.

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Answer 2

Correct Answers:

Furosemide
Parkinson's disease
Orthostatic blood pressure

Rationale :

Furosemide

✳️ Furosemide is a loop diuretic that increases urine production and can cause urinary urgency and frequent trips to the bathroom.

✳️ Frequent toileting, especially at night, increases the likelihood that the client will attempt to walk quickly or without assistance.

✳️ Furosemide can also cause fluid-volume depletion and hypotension, contributing to dizziness and instability.

✳️ Electrolyte losses, particularly reduced potassium, can produce muscle weakness that further increases fall risk.

✳️ The nurse should implement toileting assistance, monitor fluid and electrolyte status, and encourage the client to rise slowly.

Parkinson’s disease

✳️ Parkinson’s disease causes bradykinesia, rigidity, postural instability, and a shuffling gait, all of which increase fall risk.

✳️ The client may experience difficulty initiating movement and may take short, hesitant steps.

✳️ Impaired balance and reduced protective reflexes make it difficult for the client to recover after stumbling.

✳️ Episodes of freezing can occur during turning, approaching doorways, or beginning to walk.

✳️ The nurse should provide mobility assistance, maintain a clear environment, and ensure prescribed antiparkinsonian medication is administered on schedule.

Orthostatic blood pressure

✳️ The client’s blood pressure decreases from 128/56 mm Hg while sitting to 92/40 mm Hg while standing, indicating significant orthostatic hypotension.

✳️ This substantial decline can reduce cerebral perfusion and cause dizziness, blurred vision, weakness, or syncope.

✳️ Orthostatic hypotension can result from furosemide-related volume loss, Parkinson’s-related autonomic dysfunction, or medication effects.

✳️ Standing suddenly places the client at immediate risk for losing balance and falling.

✳️ The nurse should assist with position changes, have the client sit at the bedside before standing, and reassess blood pressure and symptoms.

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Answer 3

Correct Answers:

Droplet

Rationale :

🌸 Pertussis, also called whooping cough, is transmitted through large respiratory droplets produced when an infected person coughs, sneezes, or talks.

🌸 The nurse should initiate droplet precautions in addition to standard precautions upon admission.

🌸 Health care personnel should wear a surgical mask when entering the client’s room and perform strict hand hygiene.

🌸 The client should be placed in a private room when possible and should wear a mask during medically necessary transport.

🌸 Droplet precautions are generally maintained until the client has received 5 days of effective antibiotic therapy.

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Answer 4

Correct Answers:

Gloves

Rationale :

🧿 The nurse should wear gloves when changing the bed linen of a client who is on contact precautions.

🧿 Bed linen can be contaminated with microorganisms from the client’s skin, body fluids, wounds, or surrounding environment.

🧿 Gloves create a barrier that reduces direct hand exposure and prevents transmission to other clients or surfaces.

🧿 The nurse should remove the gloves immediately after handling the linen and perform thorough hand hygiene.

🧿 A gown is also commonly required when clothing could contact the client or contaminated environment, but gloves are the correct item among the options provided.

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Answer 5

Correct Answers:

2

Rationale :

✍️Formula

✔️Volume to administer=Dose prescribed/Dose on hand× Volume on hand

✔️Ordered dose: 0.5 mg IV

✔️Available: 500 mcg in 2 mL

✔️Convert: 500 mcg = 0.5 mg

✔️0.5 mg/0.5 mg×2 mL

✔️1×2 mL

💎2 mL

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Answer 6

Correct Answers:

Apply pressure to the client's nasolacrimal duct after instillation.

Rationale :

✨ Applying gentle pressure over the nasolacrimal duct limits drainage of the medication into the nasal passages.

✨ This action reduces systemic absorption of the ophthalmic medication through the highly vascular nasal mucosa.

✨ The nurse should apply pressure at the inner canthus for approximately 30 to 60 seconds, or as directed.

✨ The client should close the eyelid gently without squeezing or rubbing the eye.

✨ Nasolacrimal occlusion is especially important for medications that can produce systemic effects, such as ophthalmic beta blockers.

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Answer 7

Correct Answers:

Ensure the provider assesses the client within 60 min of restraint application.

Rationale :

✳️ A client placed in restraints for violent or self-destructive behavior must receive a face-to-face evaluation by an authorized provider within 1 hour.

✳️ The assessment evaluates the client’s physical condition, psychological status, behavior, and continued need for restraint.

✳️ The restraint order must be time limited and renewed according to the client’s age and facility policy.

✳️ The nurse must provide continuous or very frequent monitoring for circulation, respiratory status, injury, and behavioral changes.

✳️ Restraints should be discontinued at the earliest possible time when the client no longer presents an immediate danger.

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Answer 8

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available

Rationale :

💎 Gloves are removed first because they are generally the most heavily contaminated item of personal protective equipment.

💎 Eyewear is removed by handling only the headband or earpieces to avoid touching the contaminated front surface.

💎 The gown is removed by touching the inside surface and rolling it inward so the contaminated exterior is contained.

💎 The face mask is removed last by handling only the ties or elastic loops after the other contaminated equipment has been removed.

💎 Hand hygiene is performed immediately after all protective equipment is removed to eliminate organisms transferred during removal.

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Answer 9

Correct Answers:

0.8

Rationale :

💎Formula

✔️Volume to administer=Dose prescribed/Dose available ×Volume available

✔️The prescribed dose is 100 mg of hydrocortisone.

✔️The available concentration is 250 mg in 2 mL.

✔️100÷250×2.

✔️ 0.4×2

📌0.8 mL.

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Answer 10

Correct Answers:

Have the client wear a mask.

Rationale :

🎯 A client with active pulmonary tuberculosis should wear a surgical mask whenever leaving the airborne infection isolation room.

🎯 The surgical mask contains respiratory secretions and decreases the release of infectious droplet nuclei into the environment.

🎯 Transport should be limited to medically necessary procedures, and the radiology department should be informed in advance.

🎯 Staff caring for the client should use a fit-tested N95 respirator or higher-level respiratory protection according to policy.

🎯 The client should not wear an N95 respirator because source control is achieved with a standard surgical mask.

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QLexNursing

1 :
Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

2 :
A nurse is caring for a client on a medical-surgical unit.

Answer Options

3 :
A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?

4 :
A nurse is changing the bed linen for a client who is on contact precautions. Which of the following personal protective equipment should the nurse wear?

5 :
The provider prescribes digoxin 0.5 mg IV for a client with heart failure. Review the medication label. How many mL should the nurse administer for one dose?

6 :
A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan take?

7 :
A nurse is planning care for a client who has a new prescription for wrist restraints due to violent behavior. Which of the following actions should the nurse plan to take?

9 :
A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 ml. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)

10 :
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

QLexNursing

1 : Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

2 : A nurse is caring for a client on a medical-surgical unit.

Answer Options

3 : A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?

4 : A nurse is changing the bed linen for a client who is on contact precautions. Which of the following personal protective equipment should the nurse wear?

5 : The provider prescribes digoxin 0.5 mg IV for a client with heart failure. Review the medication label. How many mL should the nurse administer for one dose?

6 : A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan take?

7 : A nurse is planning care for a client who has a new prescription for wrist restraints due to violent behavior. Which of the following actions should the nurse plan to take?

9 : A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 ml. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)

10 : A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

1 :
Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

2 :
A nurse is caring for a client on a medical-surgical unit.

3 :
A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?

4 :
A nurse is changing the bed linen for a client who is on contact precautions. Which of the following personal protective equipment should the nurse wear?

5 :
The provider prescribes digoxin 0.5 mg IV for a client with heart failure. Review the medication label. How many mL should the nurse administer for one dose?

6 :
A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan take?

7 :
A nurse is planning care for a client who has a new prescription for wrist restraints due to violent behavior. Which of the following actions should the nurse plan to take?

9 :
A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 ml. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)

10 :
A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?