TEST BANK
FULL TESTBANK | RATED GRADE A|MULTICHOICES | DETAILED
RATIONALES|LATEST UPDATE| GUARANTEED PASS| 100% PASS
,When preparing to administer a prescribed medication to a homeless
client at a community psychiatric clinic. The client tells the nurse that
the usual dosage taken is different from the dose the nurse is giving.
Which action should the nurse take?
A) Inform the client that he may refuse the medication and document
whether or not the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the
next healthcare team meeting.
Answer: B) Withhold the medication until the dosage can be confirmed.
EXPERT DESCRIPTION
Medication administration requires strict adherence to safety principles,
including verification of the correct dose. When a client questions a
medication dosage, this represents a potential medication error risk and
must be taken seriously. The nurse has a legal and ethical responsibility
to hold the medication until the prescription can be verified with the
provider or appropriate source. Administering a medication with an
unverified or questionable dose could result in harm and violates safe
medication practices.
The client’s concern serves as an additional safety check in the
medication administration process. Therefore, the nurse should stop
and clarify the discrepancy before proceeding. Informing the client they
can refuse does not address the safety issue, explaining a change
,without verification is inappropriate, and administering the medication
before confirming the dose is unsafe. Thus, the correct action is to
withhold the medication until the dosage is confirmed.
The charge nurse is making assignments for one practical nurse and
three registered nurses who are caring for neurologically
compromised clients. Which client with which change in status is best
to assign to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to
170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed
from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40.
Answer: B) Viral meningitis whose temperature change from 101 S to
102F.
EXPERT DESCRIPTION
When delegating to a practical nurse (PN), the registered nurse must
assign clients who are stable and have predictable outcomes, while
avoiding clients with acute or potentially life-threatening changes in
neurological or hemodynamic status. Clients who demonstrate sudden
changes in vital signs or neurological status require the assessment
and clinical judgment of an RN.
A client with a subdural hematoma and a blood pressure change from
150/80 to 170/60 may be showing signs of increased intracranial
pressure (widening pulse pressure), which is an emergency and
, requires immediate RN assessment. Similarly, a client with diabetic
ketoacidosis who has a change in Glasgow Coma Scale score indicates
neurological deterioration, also requiring RN-level care.
In contrast, a client with viral meningitis who has a temperature
increase from 101°F to 102°F represents a predictable and expected
finding in the course of infection and is generally stable. Monitoring and
routine care for fever can be safely delegated to a PN.
The nurse is caring for a client with pneumonia who now develops
initial signs of septic shock and multi organ failure. The healthcare
provider prescribes a sepsis protocol. Which intervention is most
important for the nurse to include in the plan of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level.
Answer: A) Maintain strict intake and output.
EXPERT DESCRIPTION
Septic shock is a life-threatening condition characterized by widespread
infection, systemic inflammation, and impaired tissue perfusion, which
can rapidly progress to multi-organ failure. One of the earliest and most
critical indicators of organ perfusion—particularly renal perfusion—is
urine output. Therefore, maintaining strict intake and output is
FULL TESTBANK | RATED GRADE A|MULTICHOICES | DETAILED
RATIONALES|LATEST UPDATE| GUARANTEED PASS| 100% PASS
,When preparing to administer a prescribed medication to a homeless
client at a community psychiatric clinic. The client tells the nurse that
the usual dosage taken is different from the dose the nurse is giving.
Which action should the nurse take?
A) Inform the client that he may refuse the medication and document
whether or not the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the
next healthcare team meeting.
Answer: B) Withhold the medication until the dosage can be confirmed.
EXPERT DESCRIPTION
Medication administration requires strict adherence to safety principles,
including verification of the correct dose. When a client questions a
medication dosage, this represents a potential medication error risk and
must be taken seriously. The nurse has a legal and ethical responsibility
to hold the medication until the prescription can be verified with the
provider or appropriate source. Administering a medication with an
unverified or questionable dose could result in harm and violates safe
medication practices.
The client’s concern serves as an additional safety check in the
medication administration process. Therefore, the nurse should stop
and clarify the discrepancy before proceeding. Informing the client they
can refuse does not address the safety issue, explaining a change
,without verification is inappropriate, and administering the medication
before confirming the dose is unsafe. Thus, the correct action is to
withhold the medication until the dosage is confirmed.
The charge nurse is making assignments for one practical nurse and
three registered nurses who are caring for neurologically
compromised clients. Which client with which change in status is best
to assign to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to
170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed
from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40.
Answer: B) Viral meningitis whose temperature change from 101 S to
102F.
EXPERT DESCRIPTION
When delegating to a practical nurse (PN), the registered nurse must
assign clients who are stable and have predictable outcomes, while
avoiding clients with acute or potentially life-threatening changes in
neurological or hemodynamic status. Clients who demonstrate sudden
changes in vital signs or neurological status require the assessment
and clinical judgment of an RN.
A client with a subdural hematoma and a blood pressure change from
150/80 to 170/60 may be showing signs of increased intracranial
pressure (widening pulse pressure), which is an emergency and
, requires immediate RN assessment. Similarly, a client with diabetic
ketoacidosis who has a change in Glasgow Coma Scale score indicates
neurological deterioration, also requiring RN-level care.
In contrast, a client with viral meningitis who has a temperature
increase from 101°F to 102°F represents a predictable and expected
finding in the course of infection and is generally stable. Monitoring and
routine care for fever can be safely delegated to a PN.
The nurse is caring for a client with pneumonia who now develops
initial signs of septic shock and multi organ failure. The healthcare
provider prescribes a sepsis protocol. Which intervention is most
important for the nurse to include in the plan of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level.
Answer: A) Maintain strict intake and output.
EXPERT DESCRIPTION
Septic shock is a life-threatening condition characterized by widespread
infection, systemic inflammation, and impaired tissue perfusion, which
can rapidly progress to multi-organ failure. One of the earliest and most
critical indicators of organ perfusion—particularly renal perfusion—is
urine output. Therefore, maintaining strict intake and output is
