A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours.

Which action should the nurse take?

Place the client on contact precautions.

Start a high-fiber diet.

Administer an oral steroid.

Make the client NPO.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Placing the client on contact precautions is not indicated based on the provided orders. Contact precautions are typically used for infections that are spread by direct or indirect contact, such as MRSA or C. difficile. The orders do not suggest the presence of such an infection.
Choice B rationale
Starting a high-fiber diet is not indicated. The client is already on a regular diet, and there is no mention of conditions that would necessitate a high-fiber diet, such as constipation or diverticulosis.
Choice C rationale
Administering an oral steroid is not indicated. The orders include Cefazolin, an antibiotic, and Metformin, an antidiabetic medication. There is no indication for an oral steroid, which is typically used for inflammatory conditions or autoimmune diseases.
Choice D rationale
Making the client NPO (nothing by mouth) is the correct action. This is likely due to the need for accurate blood glucose monitoring and the administration of IV antibiotics. Being NPO ensures that the client does not eat or drink anything that could interfere with these treatments.

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Correct Answer is A

Explanation

Choice A rationale
Ensuring the bevel of the needle is pointing up is crucial when administering an intradermal injection. This technique allows the medication to be deposited just below the surface of the skin, creating a small bleb or wheal. This is important for the proper absorption and effectiveness of the medication.
Choice B rationale
Massaging the site gently after injection is not recommended for intradermal injections. Massaging can cause the medication to spread into the subcutaneous tissue, which can affect the accuracy of the test results or the effectiveness of the medication.
Choice C rationale
Holding the syringe perpendicular to the skin is not appropriate for intradermal injections. Intradermal injections should be administered at a 5 to 15-degree angle to ensure the medication is deposited just below the surface of the skin.
Choice D rationale
Selecting the upper arm as the injection site is not the best practice for intradermal injections. The preferred sites for intradermal injections are the inner surface of the forearm and the upper back below the scapula.

A. Send an email to facility administrators reporting the action. B. Dispose of the copies and continue with client care assignments. C. Warn the colleague that copying health information is unlawful. D. Communicate the colleague’s activities to the unit charge nurse.

Correct Answer is D

Explanation

Choice A rationale
While informing the colleague about the unlawful nature of copying health information is important, it may not adequately address the potential breach of patient privacy and confidentiality. Additionally, the colleague may be aware of the laws but still engage in inappropriate behavior.
Choice B rationale
Reporting the colleague’s actions to facility administrators may be necessary, but it may not be the most immediate action to take. Informing the unit charge nurse allows for more immediate intervention and resolution within the unit.
Choice C rationale
Disposing of the copies may prevent further unauthorized access to patient information, but it does not address the issue of the colleague’s inappropriate handling of the records. It’s essential to report the incident to the appropriate authority for further investigation and follow-up.
Choice D rationale
Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

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A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?

Correct Answer is D

Explanation

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A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours.

Which action should the nurse take?