Question

A nurse is preparing to administer an oral medication. Which action confirms the medication will be given at the prescribed time?

Answer 1

Correct Answers:

Reviewing when the last dose of medication was administered

Rationale :

❣️ The right time is one of the essential rights of safe medication administration.

❣️ Reviewing the time of the previous dose allows the nurse to determine whether the appropriate dosing interval has elapsed.

❣️ Giving doses too close together can cause drug accumulation, toxicity, or excessive therapeutic effects.

❣️ Delaying a medication beyond the prescribed interval may reduce its therapeutic effectiveness.

❣️ The MAR (Medication Administration Record) provides documentation of when previous doses were administered or withheld.

❣️ The nurse should compare the scheduled administration time with the last documented dose before giving the medication.

❣️ This assessment is particularly important for medications prescribed at specific intervals, such as every 4, 6, 8, or 12 hours.

❣️ Reviewing the last administration time therefore directly confirms that the medication is being given according to the prescribed timing and dosing interval.

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Answer 2

Correct Answers

Blank 1 Correct Option: gentle exercise
Blank 2 Correct Option: guided imagery

Rationale :

✅ Gentle exercise

✏️ Gentle exercise is an important nonpharmacologic intervention for clients experiencing chronic pain associated with fibromyalgia.

✏️ Regular low-impact physical activity can help decrease pain and stiffness while improving overall physical function.

✏️ Appropriate activities can include walking, swimming, stretching, and other low-impact aerobic exercises based on the client's tolerance.

✏️ Exercise can improve muscle conditioning, flexibility, endurance, and sleep quality, which are commonly affected by fibromyalgia.

✏️ Activity should generally begin at a low intensity and increase gradually to avoid excessive symptom exacerbation.

✏️ Consistency is important because prolonged inactivity can contribute to deconditioning and increased functional limitations.

✏️ Gentle exercise also supports the client's goal of managing pain without medications or invasive procedures.

✏️ A gradual, individualized exercise program can therefore be an effective component of long-term fibromyalgia pain management.

✅ Guided imagery

✏️ Guided imagery is a nonpharmacologic relaxation technique that can help decrease the perception of chronic pain.

✏️ The technique involves concentrating on calming or pleasant mental images to promote physical and psychological relaxation.

✏️ Relaxation can decrease muscle tension and reduce the stress response, both of which can influence pain perception.

✏️ Guided imagery may also help clients develop a greater sense of control over their symptoms.

✏️ It is noninvasive and does not expose the client to medication-related adverse effects.

✏️ Guided imagery can be practiced independently after the client learns the technique, making it useful for ongoing self-management.

✏️ Combining relaxation strategies with appropriate physical activity provides a multimodal nonpharmacologic approach to chronic pain.

✏️ Guided imagery therefore directly supports the client's preference to manage fibromyalgia pain without medication or invasive treatment.

❌ Acetaminophen / Ibuprofen

✏️ Acetaminophen and ibuprofen are medications, so they do not meet the client's stated preference for medication-free pain management.

✏️ These medications can also produce adverse effects when used inappropriately or for prolonged periods.

✏️ Nonpharmacologic interventions should be emphasized when they are appropriate and consistent with the client's treatment goals.

❌ Surgery / Trigger point injections

✏️ Surgery and trigger point injections involve invasive interventions and therefore conflict with the client's stated preference.

✏️ Fibromyalgia is generally managed using a multimodal approach emphasizing symptom management, physical activity, sleep, and coping strategies.

✏️ Gentle exercise and guided imagery are more consistent with the client's request for noninvasive pain management.

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Answer 3

Correct Answers:

The client is unable to empty the bladder effectively.

Rationale :

✍️ The client voided only 60 mL in 4 hours, which is a relatively small amount of urine following catheter removal.

✍️ The bladder scan showing 400 mL of retained urine indicates a significant postvoid residual volume.

✍️ A large postvoid residual means the bladder is not emptying effectively, indicating urinary retention.

✍️ Benign prostatic hyperplasia (BPH) can obstruct urinary outflow by compressing the urethra as it passes through the enlarged prostate.

✍️ The client's suprapubic discomfort further supports bladder distention caused by retained urine.

✍️ Other manifestations of urinary retention can include hesitancy, weak urinary stream, frequent small-volume voiding, and a sensation of incomplete emptying.

✍️ Continued urinary retention can cause complications such as urinary tract infection, bladder dysfunction, hydronephrosis, and kidney injury.

✍️ The nurse should recognize these findings as ineffective bladder emptying and follow the prescribed protocol for managing significant postvoid urinary retention.

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Answer 4

Correct Answers:

The client's current hemoglobin A1C is 6.8%

Rationale :

♦️ Hemoglobin A1C (HbA1c) reflects the client's average blood glucose level over approximately the previous 2–3 months.

♦️ The client's initial HbA1c was 8.9%, indicating that blood glucose was above the desired range before treatment was initiated.

♦️ At the follow-up appointment, the HbA1c decreased substantially from 8.9% to 6.8%.

♦️ This improvement provides objective laboratory evidence that the client's overall glycemic control has improved since beginning treatment.

♦️ Taking the prescribed antidiabetic medication consistently would be expected to contribute to a reduction in average blood glucose and therefore a lower HbA1c.

♦️ HbA1c is particularly useful because it reflects long-term glucose control rather than the glucose level at a single moment.

♦️ Although diet and physical activity can also improve glycemic control, the decreased HbA1c is the most objective finding among the choices demonstrating that the treatment regimen is effective.

♦️ The reduction to 6.8% therefore provides the strongest evidence that the client has been following the prescribed diabetes management regimen.

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Answer 5

Correct Answers:

3

Rationale :

⁕ Desired dose = 600 mg

⁕ Dose on hand = 200 mg

Formula:

⁕ Number of tablets = Desired dose ÷ Dose on hand

⁕ Number of tablets = 600 mg ÷ 200 mg

= 3 tablets

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Answer 6

Correct Answers:

Sterility is broken because the sterile gloved hand was lowered below waist level.

Rationale :

🏵️ In sterile technique, sterile objects and sterile-gloved hands must remain above waist level and within the nurse’s field of vision.

🏵️ Any sterile item that falls below waist level is considered contaminated, even when it does not visibly touch another object.

🏵️ Areas below the waist cannot be continuously observed and therefore cannot be reliably maintained as sterile.

🏵️ The fact that the glove remained dry does not preserve sterility once the hand was lowered below the acceptable sterile area.

🏵️ The nurse should consider the affected glove contaminated and take corrective action before continuing the procedure.

🏵️ Central venous catheter insertion requires strict surgical asepsis because the catheter provides direct access to the central circulation.

🏵️ Breaks in sterile technique can introduce microorganisms and increase the risk for a central line-associated bloodstream infection (CLABSI).

🏵️ Lowering the sterile-gloved hand below waist level therefore constitutes a break in sterility, regardless of whether a surface was touched.

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Answer 7

Correct Answers:

The client ambulates three times daily without complaints of leg discomfort.

Rationale :

🧿 Low-molecular-weight heparin (LMWH) is an anticoagulant commonly used to prevent the formation of deep vein thrombosis (DVT).

🧿 Appropriate response to prophylactic therapy is demonstrated by the absence of signs and symptoms of venous thrombosis.

🧿 Ambulating without leg pain or discomfort suggests that the client is not demonstrating clinical manifestations of a developing DVT.

🧿 Regular ambulation also promotes venous return from the lower extremities and decreases venous stasis.

🧿 LMWH primarily inhibits factor Xa, reducing the formation and extension of fibrin-containing blood clots.

🧿 The nurse should continue assessing the lower extremities for unilateral swelling, warmth, redness, tenderness, and pain.

🧿 The nurse should also monitor for anticoagulant complications such as unusual bleeding, bruising, hematuria, or gastrointestinal bleeding.

🧿 Absence of DVT manifestations while maintaining mobility therefore indicates the client is responding appropriately to prophylactic treatment.

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Answer 8

Correct Answers:

Allow the client to rest before continuing

Rationale :

✳️ Coughing during NG-tube insertion can occur when the tube irritates the pharynx or approaches the airway, so advancement should be paused.

✳️ The nurse should stop advancing the tube temporarily and allow the client to recover before attempting to continue.

✳️ The nurse should assess the client's breathing, ability to speak, oxygenation, and overall respiratory status before proceeding.

✳️ Persistent coughing, choking, cyanosis, or respiratory distress raises concern that the tube may have entered the larynx or trachea.

✳️ If respiratory distress or suspected airway placement occurs, the tube should be withdrawn rather than advanced further.

✳️ Once the client has recovered and can safely participate, insertion can be resumed according to proper NG-tube technique.

✳️ Swallowing during appropriate advancement can help guide the tube toward the esophagus, but it should not be forced while the client is actively coughing.

✳️ Allowing the client to rest protects the airway and reduces aspiration or respiratory complications during NG-tube insertion.

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Answer 9

Correct Answers:

Clean the would bed with sterile supplies before collection.

Rationale :

🖊️ Before obtaining a wound culture, the wound should be cleansed to remove surface contaminants, old drainage, and debris that could affect the specimen.

🖊️ The nurse should use sterile supplies and an appropriate cleansing solution, commonly sterile normal saline, according to facility protocol.

🖊️ Cleansing helps ensure that the specimen represents microorganisms present within the wound bed rather than organisms merely colonizing the surface.

🖊️ After cleansing, the culture specimen should be collected from viable wound tissue, rather than from old exudate or surrounding skin.

🖊️ A sterile swab may be rotated over an appropriate area of clean, viable tissue according to the prescribed culture-collection technique.

🖊️ Antiseptic solutions are generally avoided immediately before culture collection because they can destroy or inhibit microorganisms and produce inaccurate results.

🖊️ Accurate wound cultures help identify the causative organism and guide selection of appropriate antimicrobial therapy.

🖊️ Cleansing the wound bed appropriately before specimen collection therefore reduces contamination and improves the accuracy of culture results.

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Answer 10

Correct Answers:

A client with a spinal cord injury who has decreased sensation.

Rationale :

♥️ A client with a spinal cord injury is at high risk for impaired skin integrity because mobility and sensation can both be significantly decreased.

♥️ Decreased sensation prevents the client from recognizing pain or discomfort caused by prolonged pressure on the skin.

♥️ Impaired mobility may prevent the client from independently repositioning to relieve pressure over bony prominences.

♥️ Prolonged pressure compresses blood vessels and decreases tissue perfusion, causing ischemia and potentially a pressure injury.

♥️ Common high-risk areas include the sacrum, heels, hips, elbows, and other bony prominences.

♥️ The nurse should perform frequent skin assessments and implement an individualized repositioning schedule.

♥️ Pressure-redistributing surfaces, moisture management, adequate nutrition, and appropriate mobility interventions further help protect skin integrity.

♥️ The combination of sensory impairment and decreased mobility makes this client the most vulnerable to pressure-related skin breakdown.

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Test	Initial Result	Follow-Up Result	Reference Range
Hemoglobin A1C (HbA1c)	8.9%	6.8%	4–5.9%

QLexNursing

1 :
A nurse is preparing to administer an oral medication. Which action confirms the medication will be given at the prescribed time?

2 :
The nurse is caring for a client with fibromyalgia who is experiencing mild to moderate chronic pain.

Correct Answers

3 :
A nurse evaluates a client with benign prostatic hyperplasia (BPH) who voided 60 mL four hours after removal of an indwelling catheter. The client reports suprapubic discomfort. A bladder scan reveals 400 mL of retained urine. Which conclusion should the nurse make from this finding?

4 :
Patient data.

Answer Options

5 :
A nurse is preparing to administer ibuprofen 600 mg by mouth every 8 hours. Available is ibuprofen 200 mg per tablet. How many tablet(s) should the nurse administer per dose? 1 tablet(s) (If needed, round to the nearest whole number.

6 :
The nurse is assisting with a bedside insertion of a central venous catheter. While wearing sterile gloves, the nurse briefly lowers one hand below waist level without touching any surfaces. What conclusion should the nurse make?

7 :
A nurse is caring for a client receiving low-molecular-weight heparin for deep vein thrombosis (DVT) prophylaxis. Which finding indicates the client is responding appropriately to the treatment?

8 :
A nurse begins inserting a nasogastric (NG) tube, and the client begins to cough. What is an appropriate action?

9 :
A nurse is preparing to collect a wound culture from a client with signs of infection. How should the nurse cleanse the wound prior to obtaining the specimen?

10 :
The nurse is assessing a group of clients. Which client is at the greatest risk for alteration in skin integrity?

QLexNursing

1 : A nurse is preparing to administer an oral medication. Which action confirms the medication will be given at the prescribed time?

2 : The nurse is caring for a client with fibromyalgia who is experiencing mild to moderate chronic pain.

Correct Answers

3 : A nurse evaluates a client with benign prostatic hyperplasia (BPH) who voided 60 mL four hours after removal of an indwelling catheter. The client reports suprapubic discomfort. A bladder scan reveals 400 mL of retained urine. Which conclusion should the nurse make from this finding?

4 : Patient data.

Answer Options

5 : A nurse is preparing to administer ibuprofen 600 mg by mouth every 8 hours. Available is ibuprofen 200 mg per tablet. How many tablet(s) should the nurse administer per dose? 1 tablet(s) (If needed, round to the nearest whole number.

6 : The nurse is assisting with a bedside insertion of a central venous catheter. While wearing sterile gloves, the nurse briefly lowers one hand below waist level without touching any surfaces. What conclusion should the nurse make?

7 : A nurse is caring for a client receiving low-molecular-weight heparin for deep vein thrombosis (DVT) prophylaxis. Which finding indicates the client is responding appropriately to the treatment?

8 : A nurse begins inserting a nasogastric (NG) tube, and the client begins to cough. What is an appropriate action?

9 : A nurse is preparing to collect a wound culture from a client with signs of infection. How should the nurse cleanse the wound prior to obtaining the specimen?

10 : The nurse is assessing a group of clients. Which client is at the greatest risk for alteration in skin integrity?

1 :
A nurse is preparing to administer an oral medication. Which action confirms the medication will be given at the prescribed time?

2 :
The nurse is caring for a client with fibromyalgia who is experiencing mild to moderate chronic pain.

3 :
A nurse evaluates a client with benign prostatic hyperplasia (BPH) who voided 60 mL four hours after removal of an indwelling catheter. The client reports suprapubic discomfort. A bladder scan reveals 400 mL of retained urine. Which conclusion should the nurse make from this finding?

4 :
Patient data.

5 :
A nurse is preparing to administer ibuprofen 600 mg by mouth every 8 hours. Available is ibuprofen 200 mg per tablet. How many tablet(s) should the nurse administer per dose? 1 tablet(s) (If needed, round to the nearest whole number.

6 :
The nurse is assisting with a bedside insertion of a central venous catheter. While wearing sterile gloves, the nurse briefly lowers one hand below waist level without touching any surfaces. What conclusion should the nurse make?

7 :
A nurse is caring for a client receiving low-molecular-weight heparin for deep vein thrombosis (DVT) prophylaxis. Which finding indicates the client is responding appropriately to the treatment?

8 :
A nurse begins inserting a nasogastric (NG) tube, and the client begins to cough. What is an appropriate action?

9 :
A nurse is preparing to collect a wound culture from a client with signs of infection. How should the nurse cleanse the wound prior to obtaining the specimen?

10 :
The nurse is assessing a group of clients. Which client is at the greatest risk for alteration in skin integrity?