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When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

Urticaria.

Hypertension.

Diaphoresis.

Nausea.

Anxiety.

Edema.

Answer and Explanation

Correct Answer : A,C,F

Choice A rationale:

Urticaria is a skin condition characterized by the sudden appearance of raised, itchy, and red welts on the skin. It is an objective finding because it can be observed and assessed visually. The presence of urticaria may indicate an allergic reaction or another underlying condition.

Choice B rationale:

Hypertension is a subjective finding because it cannot be directly observed. It requires blood pressure measurement to confirm, making it a subjective parameter.

Choice C rationale:

Diaphoresis refers to excessive sweating, which can be observed and assessed visually. It is an objective finding and may be indicative of various conditions, including anxiety or fever.

Choice D rationale:

Nausea is a subjective symptom because it is a sensation that the client experiences and reports. It cannot be directly observed by the nurse, making it a subjective parameter.

Choice E rationale:

Anxiety is a subjective symptom, as it is a mental and emotional state experienced by the client. It cannot be directly observed, making it a subjective parameter.

Choice F rationale:

Edema is an objective finding because it can be visually assessed by the nurse. Edema is the accumulation of excess fluid in body tissues, and its presence or absence can be objectively determined.

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Correct Answer is A

Explanation

Step 1 is to determine the amount of darbepoetin alfa in each mL of solution. The vial is labeled as “60 mcg/mL”, which means each mL contains 60 mcg of darbepoetin alfa.

Step 2 is to calculate the volume of the solution that contains 40 mcg of darbepoetin alfa. This can be done by dividing the prescribed dosage by the concentration of the solution. So, the volume is 40 mcg ÷ 60 mcg/mL = 0.67 mL.

However, since we need to round to the nearest tenth, the volume becomes 0.7 mL.

So, the correct answer is, after analysing all choices, the nurse should administer 0.7 mL of the darbepoetin alfa solution.

A. Deny the medication aide's request to leave before all medications are given. B. Ask each unlicensed assistive personnel (UAP) to give medications to their assigned residents. C. Assign the remainder of medication administration to another PN who is performing treatments. D. Document why all the medications were not given to each of the residents.

Correct Answer is C

Explanation

The correct answer is Choice C: Assign the remainder of medication administration to another PN who is performing treatments.

Choice A rationale: Denying the medication aide's request to leave before all medications are given does not address the issue at hand and could potentially jeopardize patient care. It is important to acknowledge the medication aide's request and find an appropriate solution that ensures patient safety and well-being.

Choice B rationale: Delegating medication administration to unlicensed assistive personnel (UAP) who may not have the necessary training or authorization could lead to medication errors, adverse drug reactions, or other negative outcomes. It is essential to adhere to the scope of practice guidelines and facility policies when assigning tasks to UAPs.

Choice C rationale: Reassigning the medication administration to another PN with the necessary qualifications and training ensures that patients receive their medications in a safe and timely manner. This action aligns with the practical nurse's responsibility to supervise and delegate tasks appropriately, maintaining patient safety and upholding the standards of care.

Choice D rationale: Documenting why medications were not given to each resident is an important aspect of maintaining accurate and comprehensive patient records. However, it does not address the immediate need to administer medications to residents, and it is not a substitute for ensuring that patients receive their prescribed treatments. Documentation should be completed after the appropriate steps have been taken to administer medications or arrange for an alternative solution.

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When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic kidney disease receives a prescription for darbepoetin alfa 40 mcg subcutaneous every 7 days. The darbepoetin alfa vial is labeled, "60 mcg/mL." How many mL should the nurse administer? round to the nearest tenth.

Correct Answer is A

Explanation

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) take in this situation?

Correct Answer is C

Explanation

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