Question

The primary nurse went on break at 1845. During the break, the covering nurse administered the prescribed evening dose of insulin glargine and documented it manually, intending to enter it later into the electronic health record (EHR). However, the entry was never recorded electronically. When the primary nurse returned, unaware the insulin had already been given, she administered a second dose, resulting in a duplicate insulin administration.

Answer 1

Correct Answers:

Document all medications in the electronic record as soon as they are given
Involve and educate clients in medication administration
Use at least two client identifiers before administering a dose

Rationale :

🖥️Documenting medications in the electronic health record (EHR) as soon as they are administered ensures continuity and prevents duplication.

👩‍⚕️Involving clients in medication administration can serve as a safeguard, especially if they mention having already received a dose.

🆔Using at least 2 client identifiers before administering medications reinforces patient safety and ensures the correct individual receives the dose.

💉Failure to document promptly created a gap that led to an unnecessary duplicate insulin administration, risking hypoglycemia.

📌Core Message

Timely documentation, client involvement, and verifying identity are essential to prevent medication errors.

Answer 2

Correct Answers:

Obtain current client data to compare with expected outcomes.

Rationale :

🧾The nurse evaluates client outcomes by comparing current assessment findings with previously set goals.

💁‍♂️Collecting current data is necessary to objectively assess if the expected outcomes have been achieved.

🧭This comparison guides further decision-making regarding modifying interventions or maintaining the plan.

📋It ensures that evaluation is based on actual clinical data and not assumptions.

📌Core Message

Evaluating care starts by comparing current client data to the expected outcomes in the plan.

Answer 3

Correct Answers:

Ask the client for a description of the exercise schedule that is being followed.

Rationale :

🕓Timing of exercise, especially late in the day, can disrupt sleep patterns due to increased stimulation.

📅Gathering specific information about the schedule helps identify whether lifestyle habits are interfering with rest.

🔎This assessment step supports individualized client education and targeted intervention.

🧠Rather than assuming the cause, the nurse should explore the routine to tailor recommendations.

📌Core Message

Identifying the timing and routine of exercise is essential when evaluating sleep disturbances.

Answer 4

Correct Answers:

While the client is positioned in bed.

Rationale :

🛏️The mobility assessment should begin with the client's ability to move in bed, such as repositioning or limb movement.

🧠Early assessment identifies baseline strength, coordination, and any existing limitations.

📋This provides essential data before encouraging ambulation or transfers.

💪Assessing mobility in bed also helps plan for safety and needed assistance during movement.

📌Core Message

Mobility assessment begins while the client is in bed to determine baseline function and safety.

Answer 5

Correct Answers:

Obtain a bedside commode for the client to use.

Rationale :

🚽A bedside commode offers a more convenient and private solution for clients who may not reach the bathroom in time.

🦵It promotes dignity while accommodating physical limitations during procedures like enemas.

🛑This approach prevents accidents and respects the client’s need for timely elimination.

🧍‍♀️It’s a proactive response aligned with client safety and comfort.

📌Core Message

A bedside commode ensures timely and safe elimination while maintaining client dignity.

Answer 6

Correct Answers:

Explain that a popsicle or a cup of gelatin can be provided rather than ice cream.

Rationale :

🍦Ice cream is not part of a clear liquid diet because it contains milk proteins and fats, making it opaque.

📚Educating the client about diet restrictions supports adherence to pre-surgical requirements.

🍮Gelatin and popsicles are clear at room temperature and meet the criteria for a clear liquid diet.

💬Offering alternatives demonstrates therapeutic communication while ensuring compliance.

📌Core Message

Only transparent items like gelatin or popsicles meet the requirements of a clear liquid diet.

Answer 7

Correct Answers:

A client must be willing to accept palliative care, not curative care.
The healthcare provider must project that the client has 6 months or less to live.

Rationale :

💊Hospice care is appropriate when the client agrees to palliative, not curative interventions.

🕰️The requirement includes a provider prognosis of 6 months or less based on disease progression.

📋These criteria guide referral eligibility and ensure proper use of hospice services.

📚Family agreement is not a legal necessity, but the client's understanding and consent are critical.

📌Core Message

Hospice eligibility requires accepting palliative care and a six-month prognosis from the provider.

Answer 8

Correct Answers:

"How much water and ice chips do you have each day?"

Rationale :

💧Hyponatremia (low sodium) can result from excessive free water intake, diluting serum sodium.

🧠Sodium is a critical electrolyte for neurological and fluid balance, and intake affects levels directly.

🧪Exploring water and ice consumption helps identify possible causes for electrolyte imbalance.

🧂The nurse needs to correlate fluid habits with lab findings to guide intervention.

📌Core Message

Investigating water intake is essential when assessing causes of low sodium levels.

Answer 9

Correct Answers:

Basilar lung sounds that are diminished in the left lung.

Rationale :

💁‍♂️Charting by exception requires documentation of abnormal findings, not routine ones.

🔍Diminished breath sounds are not normal and must be recorded for clinical follow-up.

📋This ensures communication of findings that may indicate conditions like atelectasis or effusion.

🧾Routine or expected values like bowel sounds or capillary refill may not need documentation in this system.

📌Core Message

Abnormal findings such as diminished lung sounds must be documented under charting by exception.

Answer 10

Correct Answers:

Start the collection time now and stop the collection the next day at the same time.

Rationale :

⏰A 24-hour urine collection begins after emptying the bladder and noting the exact start time.

🧪Timing is crucial for ensuring a complete and accurate sample of urinary output and analytes.

📅The collection must continue for a full 24 hours, ending at the same time the next day.

📋Proper timing affects the validity of diagnostic results such as creatinine clearance.

📌Core Message

A 24-hour urine collection must begin immediately after bladder emptying and run for an exact 24-hour period.

Answer Options

📌Core Message

Timely documentation, client involvement, and verifying identity are essential to prevent medication errors.

2 :
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care (POC). Which action should the nurse take next?

3 :
A client tells the nurse about doing a high intensity workout program to help with losing weight but now describes having difficulty getting to sleep at night. Which action should the nurse implement?

4 :
The nurse is performing an initial mobility assessment with a new client. When should the nurse start the mobility assessment?

5 :
Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

6 :
A clear liquid breakfast is prescribed for a client who is scheduled for surgery later today. The client asks the nurse for a small cup of chocolate ice cream. Which action should the nurse take?

7 :
A family member of a frail older adult asks the nurse about eligibility requirements for hospice care. Which information should the nurse provide? Select all that apply.

8 :
The home health nurse visits a client who has a serum sodium level of 123 mEq/L (123 mmol/L). To explore possible etiologies for this value, which question should the nurse ask the client?
Reference Range:
Sodium [135 to 145 mEq/L (135 to 145 mmol/L)]

9 :
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

10 :
The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After all the urine is emptied from the collection bag, which action is most important for the nurse to implement?

Answer Options

📌Core Message

Timely documentation, client involvement, and verifying identity are essential to prevent medication errors.

2 : When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care (POC). Which action should the nurse take next?

3 : A client tells the nurse about doing a high intensity workout program to help with losing weight but now describes having difficulty getting to sleep at night. Which action should the nurse implement?

4 : The nurse is performing an initial mobility assessment with a new client. When should the nurse start the mobility assessment?

5 : Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

6 : A clear liquid breakfast is prescribed for a client who is scheduled for surgery later today. The client asks the nurse for a small cup of chocolate ice cream. Which action should the nurse take?

7 : A family member of a frail older adult asks the nurse about eligibility requirements for hospice care. Which information should the nurse provide? Select all that apply.

8 : The home health nurse visits a client who has a serum sodium level of 123 mEq/L (123 mmol/L). To explore possible etiologies for this value, which question should the nurse ask the client?Reference Range:Sodium [135 to 145 mEq/L (135 to 145 mmol/L)]

9 : A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

10 : The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After all the urine is emptied from the collection bag, which action is most important for the nurse to implement?

2 :
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care (POC). Which action should the nurse take next?

3 :
A client tells the nurse about doing a high intensity workout program to help with losing weight but now describes having difficulty getting to sleep at night. Which action should the nurse implement?

4 :
The nurse is performing an initial mobility assessment with a new client. When should the nurse start the mobility assessment?

5 :
Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

6 :
A clear liquid breakfast is prescribed for a client who is scheduled for surgery later today. The client asks the nurse for a small cup of chocolate ice cream. Which action should the nurse take?

7 :
A family member of a frail older adult asks the nurse about eligibility requirements for hospice care. Which information should the nurse provide? Select all that apply.

8 :
The home health nurse visits a client who has a serum sodium level of 123 mEq/L (123 mmol/L). To explore possible etiologies for this value, which question should the nurse ask the client?
Reference Range:
Sodium [135 to 145 mEq/L (135 to 145 mmol/L)]

9 :
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

10 :
The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After all the urine is emptied from the collection bag, which action is most important for the nurse to implement?