The home health nurse notes the client has gained 5 pounds overnight and has increased edema in the lower extremities. The nurse is calling the physician to obtain an order over the phone for furosemide medication. The physician gives an order and the nurse enters the order in the client's medical record. What will the nurse do next after writing down the order?

Call the pharmacy and see if the medication is available.

Initiate the prescription and administer the medication.

Read back the order to the physician.

Draw the medication into an appropriately labeled syringe.

Answer and Explanation

The Correct Answer is C

Answer and Explanation

The correct answer is choice C, Read back the order to the physician.

After obtaining the physician's order over the phone, the nurse should read back the order to the physician to confirm accuracy and prevent medication errors.

This process ensures that the order is correctly transcribed and the right medication, dose, and route are given to the patient. Calling the pharmacy to check medication availability is not the nurse's responsibility, and initiating the prescription and administering the medication is inappropriate without confirming the order with the physician. Drawing up the medication into an appropriately labeled syringe before confirming the order with the physician is also inappropriate and can lead to medication errors. Therefore, reading back the order to the physician is the most appropriate action for the nurse to take.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choice B, Use water and mild soap.

When teaching a patient about ostomy care, the nurse should instruct the patient to clean the area around the ostomy with water and mild soap. Using a whirlpool bath, alcohol-based sanitizer, or chlorhexidine or HCG is not recommended as they can irritate the skin and damage the stoma. Cleansing the ostomy area with water and mild soap is the best way to maintain the skin's integrity and prevent irritation and infection.

A. Apply restraints to the hands or wrists to keep the patient in bed. B. Place a belt restraint on the client when they are sitting in a chair. C. Keep the bed in lowest position with all four side rails up. D. Educate the patient on using the call light and make sure the call light is within reach.

Correct Answer is D

Explanation

A. Apply restraints to the hands or wrists to keep the patient in bed:Restraints should only be used when absolutely necessary and as a last resort, and the client in this scenario is oriented and can follow instructions. Restraints can also increase the risk of injury, agitation, and further falls.

B. Place a belt restraint on the client when they are sitting in a chair:Belt restraints restrict movement and should only be used when other measures are insufficient to protect the client. Since the client is oriented and can follow directions, this intervention is not warranted and could cause harm.

C. Keep the bed in the lowest position with all four side rails up:
Incorrect. Raising all four side rails is considered a form of restraint and can increase the risk of injury. Clients may attempt to climb over the side rails, leading to falls. Keeping the bed in a low position is appropriate, but using all four side rails is not.

D. Educate the patient on using the call light and make sure the call light is within reach.This is the most appropriate action as the client is oriented and can follow directions. Educating the patient on how to use the call light and ensuring it is easily accessible encourages them to ask for assistance when needed, reducing the risk of falls.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a patient with a new ostomy about skin care to preserve tissue integrity. What teaching will the nurse provide about cleansing the ostomy area?

Correct Answer is B

Explanation

A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Correct Answer is D

Explanation

Upon responding to the client's call bell, the nurse discovers the client's abdominal wound has been eviscerated. Initial nursing management includes calling the healthcare provider and which other initial action?

A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

A nurse is interviewing a newly admitted patient. What question would best exhibit cultural competence?

The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

A nurse is implementing interventions to prevent a patient from developing Deep Vein Thrombosis (DVT) in the legs by applying a pneumatic or sequential compression device (SCD's). Which explanation would the nurse give the patient in regards to how this device works?

A nurse is assisting a patient who is 2 days postoperative from an abdominal surgery to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient tells the nurse she feels faint. What should be the nurse's immediate action to keep the patient safe?

What is the rationale for using continuous positive air pressure (CPAP) to treat sleep apnea?

Which of the following scenarios would represent proper delegation as applies to delegating care to the right professional?