Question

A nurse administers a dose of acetaminophen 1,000 mg (two 500 mg tablets) to an adult client for a severe headache. Twenty minutes later, a second nurse inadvertently administers an identical second dose of acetaminophen 1,000 mg for the same complaint. After assessing the client, notifying the healthcare provider, and completing an institutional incident report, which entry should the nurse document in the client's permanent medical record?

Answer 1

Correct Answers:

"Acetaminophen 1000 mg administered at 1400. Inadvertent second dose of 1000 mg administered at 1420. Healthcare provider notified, client assessed with no acute distress, and vital signs remain stable."

Rationale :

📄 The client's permanent medical record should contain objective, factual information about what occurred and the client's clinical status.

📄 The documentation appropriately records the exact medication, doses, and administration times of both acetaminophen doses.

📄 Recording that the healthcare provider was notified demonstrates that appropriate follow-up occurred after identifying the medication error.

📄 Documentation that the client was assessed establishes that the nurse evaluated the client for possible adverse effects.

📄 Recording no acute distress and stable vital signs provides objective information about the client's condition following the error.

📄 The entry avoids assigning blame to another nurse or describing speculation about why the medication error occurred.

📄 The permanent medical record should not mention an incident report, variance report, or risk-management process, because those documents are maintained separately for quality improvement and risk management.

📄 This entry therefore provides the clinically relevant facts necessary for continuity of care while maintaining appropriate separation between the medical record and institutional incident-reporting system.

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Answer 2

Correct Answers:

"Tell me about the visit with your significant other."

Rationale :

🗣️ “Tell me about…” is an open-ended therapeutic communication technique that encourages the client to describe the experience in their own words.

🗣️ The client's increased isolation and refusal to attend group occurred after the visit, suggesting that something about the interaction may have affected the client's emotional state.

🗣️ This response allows the client to discuss both positive and negative aspects of the visit without the nurse making assumptions.

🗣️ The nurse avoids interpreting the client's feelings before the client has had an opportunity to identify and express them.

🗣️ Open-ended statements encourage exploration of thoughts, feelings, perceptions, and concerns.

🗣️ The response focuses directly on the event preceding the behavioral change, helping the nurse gather clinically relevant information.

🗣️ Therapeutic communication promotes trust and self-expression while allowing the client to control how much information to disclose.

🗣️ Asking the client to describe the visit is therefore the most therapeutic approach because it facilitates exploration without judgment, assumptions, or leading questions.

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Answer 3

Correct Answers:

Risk for impaired skin integrity.

Rationale :

🦶 Peripheral neuropathy decreases the client's ability to perceive pain, pressure, temperature, and injuries involving the feet.

🦶 Increasing numbness and tingling indicate worsening sensory impairment, making unnoticed foot trauma more likely.

🦶 The client may develop blisters, cuts, burns, pressure areas, or ulcers without recognizing that an injury has occurred.

🦶 Loss of protective sensation makes impaired skin integrity the priority problem when planning preventive foot care.

🦶 The nurse should teach the client to inspect both feet every day, including the soles and areas between the toes.

🦶 Proper foot care includes keeping the feet clean and dry, wearing properly fitting shoes, and avoiding walking barefoot.

🦶 The client should avoid heating pads, hot water, and other direct heat sources because decreased sensation increases the risk for burns.

🦶 Preventing skin breakdown is particularly important because an unnoticed injury can progress to ulceration, infection, and potentially serious tissue damage.

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Answer 4

Correct Answers:

Avoid alcohol in the evening
Avoid naps
Try to go to bed and awaken at the same time every day

Rationale :

🌙 Avoid alcohol in the evening — CORRECT

🌙 Although alcohol can initially cause drowsiness, it does not promote normal restorative sleep.

🌙 Alcohol commonly causes fragmented sleep and can increase awakenings later during the night.

🌙 The client drinks 1 to 2 glasses of wine every evening, making this particularly relevant to her sleep problems.

🌙 Alcohol can interfere with normal sleep architecture, including REM sleep.

🌙 As alcohol is metabolized during the night, its sedating effect decreases and sleep disruption can occur.

🌙 Avoiding evening alcohol may therefore reduce the client's reported multiple nighttime awakenings.

🌙 The nurse should encourage the client to use nonalcoholic relaxation strategies rather than alcohol as a sleep aid.

🌙 Eliminating or reducing evening alcohol is an important component of appropriate sleep hygiene.

🌙 Avoid naps — CORRECT

🌙 Daytime naps can decrease the body's natural sleep drive that develops throughout the day.

🌙 Reduced sleep drive can make it more difficult for a person with insomnia to fall asleep at bedtime.

🌙 This client already requires 1 to 2 hours to fall asleep, making preservation of nighttime sleep drive important.

🌙 Avoiding naps helps consolidate sleep into the intended nighttime period.

🌙 Daytime sleepiness may make napping tempting, but frequent or prolonged naps can perpetuate the insomnia cycle.

🌙 Staying awake during the day supports development of sufficient physiological sleep pressure by bedtime.

🌙 Consistent daytime wakefulness also helps reinforce the body's normal circadian rhythm.

🌙 Avoiding naps is therefore an appropriate behavioral intervention for improving nighttime sleep quality.

🌙 Try to go to bed and awaken at the same time every day — CORRECT

🌙 Maintaining consistent sleep and wake times helps regulate the body's circadian rhythm.

🌙 The client should follow the schedule consistently, including weekends, whenever possible.

🌙 A regular wake time helps synchronize the body's internal biological clock with the external day-night cycle.

🌙 Consistency can gradually make it easier to become sleepy at an appropriate time each evening.

🌙 Regular sleep scheduling also discourages sleeping late after a night of poor sleep, which can perpetuate insomnia.

🌙 A predictable routine strengthens behavioral associations between bedtime and sleep.

🌙 This intervention is a fundamental component of sleep hygiene and behavioral management of chronic insomnia.

🌙 Maintaining a consistent sleep-wake schedule can help improve both sleep initiation and overall sleep quality.

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Answer 5

Correct Answers:

The client will demonstrate ability to change the ostomy bag in two days.

Rationale :

🎯 An appropriate outcome statement describes a specific behavior or response that the client is expected to achieve.

🎯 This outcome is client-centered because it focuses on what the client will accomplish rather than what the nurse will do.

🎯 The word “demonstrate” identifies an observable behavior that the nurse can directly evaluate.

🎯 Changing the ostomy bag is an important self-care skill the client will need after discharge following colostomy placement.

🎯 The phrase “in two days” provides a specific time frame for achievement of the outcome.

🎯 The nurse can objectively determine whether the outcome has been met, partially met, or not met by observing the client's performance.

🎯 Effective nursing outcomes should be specific, measurable, attainable, relevant, and time-limited (SMART).

🎯 This statement therefore represents the best postoperative outcome because it contains a client behavior, measurable performance, and defined time frame.

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Answer 6

Correct Answers:

Polish on the fingernails.
Bruising on the hand.
Weak, thready radial pulse.

Rationale :

🫁 Polish on the fingernails — CORRECT

🫁 Nail polish, particularly darker colors, can interfere with the transmission and absorption of light used by the pulse oximeter.

🫁 A pulse oximeter estimates oxygen saturation by passing specific wavelengths of light through the tissue.

🫁 Nail polish can alter the amount of light reaching the sensor and potentially produce an inaccurate reading.

🫁 The nurse should inspect the client's nail before accepting an unexpectedly low oxygen saturation value.

🫁 Removing the polish may improve the reliability of the measurement.

🫁 The probe can also be repositioned to another suitable site when nail polish cannot be removed.

🫁 An unexpectedly low SpO₂ should always be interpreted together with the client's respiratory assessment and clinical appearance.

🫁 Nail polish therefore gives the nurse a reason to question the accuracy of the 88% reading.

🫁 Bruising on the hand — CORRECT

🫁 Bruising can interfere with light transmission through the tissue and affect pulse oximeter measurements.

🫁 A bruise contains blood that has leaked into surrounding tissues, potentially altering light absorption.

🫁 The nurse should avoid placing the pulse oximeter over tissue that is bruised, injured, or compromised when possible.

🫁 Local tissue changes can make it more difficult for the sensor to distinguish arterial pulsations accurately.

🫁 The nurse should inspect the finger and surrounding hand when evaluating an unexpected SpO₂ measurement.

🫁 Selecting an unaffected finger or alternative site can help determine whether the original value was accurate.

🫁 Rechecking the saturation at another appropriate site provides additional information before concluding that the client has true hypoxemia.

🫁 The presence of bruising therefore provides a reasonable basis for questioning the accuracy of the pulse oximeter reading.

🫁 Weak, thready radial pulse — CORRECT

🫁 A weak, thready pulse suggests decreased peripheral perfusion, which can significantly affect pulse oximetry accuracy.

🫁 Pulse oximeters require adequate pulsatile arterial blood flow to distinguish arterial blood from surrounding tissues.

🫁 Poor peripheral circulation decreases the strength of the signal detected by the sensor.

🫁 Conditions such as hypotension, shock, vasoconstriction, hypothermia, and reduced cardiac output can similarly produce unreliable measurements.

🫁 A weak radial pulse indicates that blood flow to the finger may be insufficient for a dependable reading.

🫁 The nurse should compare the displayed pulse rate with the client's actual pulse and evaluate the device's signal quality when available.

🫁 Repositioning the probe or using a better-perfused site may produce a more reliable oxygen saturation measurement.

🫁 Poor peripheral perfusion therefore makes the reported 88% SpO₂ potentially inaccurate and warrants reassessment.

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Answer 7

Correct Answers:

Connect the tubing to the flow meter.

Rationale :

🫁 The nasal cannula cannot deliver the prescribed oxygen when the oxygen tubing is disconnected from the flow meter.

🫁 The nurse should first correct the obvious problem by reconnecting the tubing to the oxygen source.

🫁 Oxygen flowing from the meter does not reach the client unless there is a continuous connection between the flow meter, tubing, and nasal cannula.

🫁 A setting of 1.5 L/min is within the usual low-flow range that can be delivered through a nasal cannula.

🫁 Reconnecting the tubing restores the prescribed oxygen therapy without unnecessarily changing the ordered flow rate.

🫁 After reconnecting the tubing, the nurse should verify that oxygen is flowing through the cannula and reassess the client's oxygenation.

🫁 The nurse should evaluate the client's oxygen saturation, respiratory rate, work of breathing, and overall respiratory status after correcting the problem.

🫁 Correcting an immediately identifiable equipment problem follows appropriate nursing priority by restoring the client's prescribed oxygen delivery promptly.

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Answer 8

Correct Answers:

Puts on new gloves when entering a client's room.

Rationale :

🧤 Gloves are single-use PPE and should be applied when contact with blood, body fluids, mucous membranes, nonintact skin, or contaminated materials is anticipated.

🧤 A new pair of gloves should be used for each client-care situation requiring gloves.

🧤 Gloves help prevent contamination of the UAP's hands and reduce transmission of microorganisms between clients.

🧤 Gloves should be donned immediately before the anticipated exposure or task rather than being worn unnecessarily throughout the unit.

🧤 Gloves must be changed between clients and between contaminated and clean tasks on the same client when indicated.

🧤 After completing care, the UAP should remove the gloves appropriately and perform hand hygiene.

🧤 Wearing gloves does not replace hand hygiene because contamination can occur during glove removal or through microscopic defects.

🧤 Using a fresh pair of gloves for client care demonstrates understanding of standard precautions and infection-prevention practices.

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Answer 9

Correct Answers:

Ensure bevel of the needle is pointing up.

Rationale :

💉 For an intradermal (ID) injection, the needle is inserted with the bevel facing upward.

💉 Positioning the bevel upward allows the medication to be deposited correctly within the dermis, immediately beneath the epidermis.

💉 The needle is inserted at a shallow angle of approximately 5 to 15 degrees to the skin.

💉 Correct intradermal administration should produce a small raised wheal or bleb at the injection site.

💉 Intradermal injections are commonly used for tuberculin skin testing and allergy testing.

💉 Only a small volume of medication, commonly about 0.1 mL, is administered because the dermal layer has limited capacity.

💉 The nurse should stabilize the skin and insert the needle only far enough for the bevel to enter the dermis.

💉 A bevel-up, shallow-angle technique ensures proper placement of the medication and supports accurate interpretation of intradermal testing.

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Answer 10

Correct Answers:

Determine if the corneas are dry.

Rationale :

👁️ A diminished blink reflex reduces the client's ability to naturally lubricate and protect the surface of the eyes.

👁️ Normal blinking distributes tears across the cornea, keeping the ocular surface moist and protected.

👁️ An unresponsive client may not completely close the eyelids, further increasing evaporation of tears.

👁️ The nurse should assess the eyes for corneal dryness, redness, irritation, cloudiness, and incomplete eyelid closure.

👁️ Persistent dryness can lead to corneal injury, abrasion, ulceration, and discomfort.

👁️ Appropriate comfort measures may include prescribed artificial tears or lubricating ophthalmic ointment.

👁️ Gentle eye care and protection of the corneas are important components of comfort-focused hospice nursing care.

👁️ Assessing for corneal dryness directly addresses the physiological consequence of the client's diminished protective blink reflex.

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QLexNursing

2 :
A client assigned to a mental health unit visits with the significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

3 :
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

4 :
Patient Data

Answer Options

6 :
A client's oxygen saturation level is 88% via a pulse oximeter probe placed on the client's third finger of the left hand. Which factor(s) can cause the nurse to question the accuracy of this value? Select all that apply.

7 :
The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

8 :
The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

9 :
The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

10 :
During report the nurse receives information on an adult client receiving hospice care. The client has been unresponsive with a diminished blink reflex. Which intervention should the nurse perform?

QLexNursing

2 : A client assigned to a mental health unit visits with the significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

3 : The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

4 : Patient Data

Answer Options

6 : A client's oxygen saturation level is 88% via a pulse oximeter probe placed on the client's third finger of the left hand. Which factor(s) can cause the nurse to question the accuracy of this value? Select all that apply.

7 : The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

8 : The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

9 : The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

10 : During report the nurse receives information on an adult client receiving hospice care. The client has been unresponsive with a diminished blink reflex. Which intervention should the nurse perform?

2 :
A client assigned to a mental health unit visits with the significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

3 :
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

4 :
Patient Data

6 :
A client's oxygen saturation level is 88% via a pulse oximeter probe placed on the client's third finger of the left hand. Which factor(s) can cause the nurse to question the accuracy of this value? Select all that apply.

7 :
The nurse determines that a client's oxygen flow meter is set at 1.5 L/minute, the nasal cannula is in place in the client's nares, and the oxygen tubing is disconnected from the flow meter. Which action would the nurse implement?

8 :
The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

9 :
The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

10 :
During report the nurse receives information on an adult client receiving hospice care. The client has been unresponsive with a diminished blink reflex. Which intervention should the nurse perform?