The nurse is preparing a prescribed medication for a client from an ampule. Which of the following actions should the nurse take? Select all that apply.

Scrub the stem of the ampule with antimicrobial wipe.

Break the stem of the ampule away from the body

Attach a filter needle to the syringe.

Tap the stem of the ampule.

Wrap the stem of the ampule with a sterile gauze pad.

Answer and Explanation

Correct Answer : B,C,E

A. Scrub the stem of the ampule with an antimicrobial wipe. This is not necessary because the stem of the ampule is broken and is not typically touched with hands or contaminated. The main concern is to prevent any glass from falling into the medication.

B. Break the stem of the ampule away from the body. Breaking the stem away from the body helps to prevent any shards of glass from falling into the medication or causing injury.

C. Attach a filter needle to the syringe. A filter needle is used to prevent any glass particles from entering the syringe when drawing up the medication from an ampule.

D. Tap the stem of the ampule. Tapping the stem may help remove any bubbles but is not a standard practice in ampule preparation.

E. Wrap the stem of the ampule with a sterile gauze pad. Wrapping the stem with a sterile gauze pad provides protection from glass shards and helps prevent injury when breaking the ampule.

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Correct Answer is B

Explanation

A. Gait belt with handles: A gait belt can provide support and stability during transfers, but it is generally used for walking rather than transferring directly from bed to chair.

B. Lateral-assist transfer board: A lateral-assist transfer board can help with moving the patient from bed to chair by sliding, making it appropriate for this transfer scenario.

C. Powered stand-assist aid: A powered stand-assist aid is typically used to help patients who need assistance standing and could be appropriate if the patient requires more support during the transfer.

D. Powered full-body lift: A powered full-body lift is generally used for patients who cannot bear weight at all and would not be necessary for a patient who can bear weight on one leg and use a walker.

A. Verify the client's code status. B. Begin cardiopulmonary resuscitation. C. Provide comfort measures until family arrives. D. Initiate a slow code response.

Correct Answer is B

Explanation

A. Verify the client's code status: Although verifying code status is important, it may delay necessary emergency interventions. In an urgent situation where the code status is unknown, immediate action is required.

B. Begin cardiopulmonary resuscitation (CPR). When a client is pulseless and the code status is unknown, the priority is to start CPR while emergency services are called. This ensures that the client receives potentially life-saving care promptly.

C. Provide comfort measures until family arrives. This is not appropriate if the client is pulseless and immediate resuscitation efforts are needed.

D. Initiate a slow code response. A slow code is not appropriate in an emergency situation where the patient requires immediate resuscitation.

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The nurse is preparing a prescribed medication for a client from an ampule. Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to transfer a patient from the bed to a chair next to the bed. The patient has full weight bearing on the right leg and partial weight bearing on the left leg. They use a walker when ambulating. Which of the following assistive devices would be appropriate for the transfer?

Correct Answer is B

Explanation

The nurse is caring for a client with a terminal illness who has become pulseless. The code status for the client is unknown to the nurse and a hospital emergency response is called. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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