Which intervention is most important for the nurse to implement when administering medications?

Elevate the head of the bed to at least 45 degrees.

Use at least two different methods to identify the client.

Provide a fresh glass of water for taking the medications.

Recheck the prepared medications against the medication administration record (MAR).

Answer and Explanation

The Correct Answer is B

A. Elevating the head of the bed is important for swallowing and preventing aspiration but is secondary to ensuring correct patient identification.
B. Using at least two different methods to identify the client is the most important step to prevent medication errors. This ensures that the correct medication is given to the correct patient.
C. Providing water is helpful but not as critical as ensuring the correct patient is identified.
D. Rechecking the medications against the MAR is important but should be done in conjunction with proper patient identification.

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Correct Answer is B

Explanation

A. Administering albuterol may help if the shortness of breath is due to bronchospasm, but the priority in heart failure is to assess fluid status and respiratory function.
B. Listening to lung fields is crucial to assess for signs of pulmonary edema, which is a common complication in heart failure. This assessment helps determine the effectiveness of the furosemide and whether further intervention is needed.
C. Measuring urine output is important but secondary to assessing respiratory status.
D. Reviewing serum potassium is important but not as urgent as assessing the client's respiratory status.

A. Apply lubricating lotion to the areas. B. Refer the client for a skin lesion biopsy. C. Ask about recent international travel. D. Record the presence of senile lentigines.

Correct Answer is D

Explanation

A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.

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Which intervention is most important for the nurse to implement when administering medications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with heart failure reports increased shortness of breath. The nurse administered furosemide 20 mg IV 60 minutes ago. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

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