A charge nurse is supervising a newly licensed nurse who is caring for a client who is experiencing auditory hallucinations and is refusing medication. The newly licensed nurse suggests placing the medication in the client's food to the charge nurse. Which of the following actions should the charge nurse take?

Suggest the family persuade the client to take the medication.

Recommend that the medication be delivered intramuscularly.

Remind the newly licensed nurse that the client has a right to refuse medication.

Suggest the newly licensed nurse contact the pharmacy to inquire about compatible foods.

Answer and Explanation

The Correct Answer is C

The charge nurse should remind the newly licensed nurse that the client has a right to refuse medication. It is important for healthcare providers to respect the autonomy and rights of their clients, including the right to refuse treatment.

Option a is incorrect because it may not be appropriate for the family to persuade the client to take medication against their wishes.

Option b is incorrect because delivering medication intramuscularly against the client's wishes would violate their right to refuse treatment.

Option d is incorrect because inquiring about compatible foods with the pharmacy would not address the issue of the client's right to refuse medication.

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Correct Answer is A

Explanation

A nurse admitting a client who has active tuberculosis should place the client in a room that is ventilated to

the outside. This is an appropriate nursing intervention to prevent the spread of tuberculosis to others.

The other options are not correct.

b) The nurse does not need to wear a gown when delivering the client's food tray but should wear a mask and gloves.

c) Visitors are not prohibited while the client's infection is activebut should be limited and should wear masks.

d) A tuberculin skin test is not necessary prior to discharge as the client has already been diagnosed with active tuberculosis.

A. Respiratory alkalosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory acidosis

Correct Answer is C

Explanation

A nurse reviewing the laboratory results of a client who has DKA should identify that the client's ABG results of pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L indicate metabolic acidosis. Metabolic acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L).

The other options are not correct.

a) Respiratory alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a low PaCO₂ (less than 35 mm Hg).

b) Metabolic alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a high bicarbonate level (greater than 26 mEq/L).

d) Respiratory acidosisis an acid-base imbalance characterized by a low pH (less than 7.35) and a high PaCO₂ (greater than 45 mm Hg).

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has active tuberculosis. Which of the following nursing interventions is appropriate?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results of a client who has DKA. The client's ABG results are pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L. The nurse should identify that these values indicate which of the following acid-base imbalances?

Correct Answer is C

Explanation

A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following findings should the nurse expect?

A nurse is preparing to administer 5 units of regular insulin and 20 units of NPH insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take first?

A nurse is collecting data from a client whose Hgb is 8.8 mg/dL. Which of the following statements should the nurse expect?

A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understanding of the teaching?

A nurse is caring for a client who was recently admited to an inpatient mental health unit. The client tells the nurse that he is not coming out of his room anymore because other clients on the unit make fun of him. Which of the following responses by the nurse is appropriate?

A nurse is caring for a client who is breastfeeding their 5-day-old newborn. Which of the following should the nurse identify as an indication that the newborn is breastfeeding eﬀectively?

A nurse is reviewing the medical record for a client who is at 38 weeks of gestation, tested positive for group B streptococcus B-hemolytic, and is allergic to penicillin. The nurse should identify that which of the following medications is contraindicated for this client?

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?