The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

Explain that since the medication is a controlled substance, it must be taken.

Credit the medication back and put it in the client's medication box.

Keep the medication and see if the client will want to take it later.

Have another nurse witness the disposal of the medication into the disposal container.

Answer and Explanation

The Correct Answer is D

Choice A reason: The nurse cannot force the client to take medication against their will, even if it is a controlled substance.

Choice B reason: Crediting the medication back and placing it in the client's medication box is not appropriate as the medication has already been removed from the unit dose wrapper.

Choice C reason: Keeping the medication to see if the client will want to take it later is not safe practice as it could lead to medication errors or misuse.

Choice D reason: The nurse should dispose of the medication properly, and having another nurse witness the disposal is a standard procedure to ensure that controlled substances are accounted for.

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Correct Answer is A

Explanation

Choice A reason: The results are within the normal reference range for both potassium and sodium, which is expected unless the client's condition has led to significant electrolyte imbalances.

Choice B reason: A serum potassium level of 4.5 mEq/L is at the higher end of the normal range, which might not be expected in a client with vomiting and diarrhea, conditions that often lead to lower potassium levels.

Choice C reason: A serum potassium level of 5.0 mEq/L is at the upper limit of the normal range and could indicate hyperkalemia, especially in the context of severe dehydration.

Choice D reason: A serum sodium level of 149 mEq/L is slightly above the normal range and could indicate hypernatremia, which may occur in dehydration but would require further assessment and intervention.

A. Complete the intermittent suction of the nasopharynx. B. Apply an oxygen mask over the client's nose and mouth. C. Reposition the pulse oximeter clip to obtain a new reading. D. Stop suctioning until the pulse oximeter reading is above 95%.

Correct Answer is A

Explanation

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

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The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

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