,
,A nurse is preparing to administer a medication to a client. Which of the following actions
should the nurse take first?
A. Check the client's identification band
B. Verify the medication with a second nurse
C. Administer the medication as prescribed
D. Document the medication administration
, Answer: A. Check the client's identification band
Rationale: The first step in medication administration is to verify the client's identity using
two identifiers, such as the identification band and asking the client to state their name.
A nurse is caring for a client who has a new prescription for a cleansing enema. Which of the
following positions should the nurse place the client in?
A. Supine
B. Left lateral Sims' position
C. Prone
D. High Fowler's
Answer: B. Left lateral Sims' position
Rationale: The left lateral Sims' position allows gravity to help the solution flow into the
colon and promotes retention.
A nurse is performing hand hygiene. Which of the following actions indicates the need for
further teaching?
A. Using alcohol-based hand rub when hands are visibly soiled
B. Washing hands for at least 20 seconds
C. Using soap and water after caring for a client with C. difficile
D. Keeping fingernails short and clean
Answer: A. Using alcohol-based hand rub when hands are visibly soiled
Rationale: Alcohol-based hand rubs are not effective when hands are visibly soiled or
contaminated with blood or body fluids. Soap and water must be used.
A nurse is assessing a client's vital signs. Which of the following findings should the nurse
report immediately?
A. Blood pressure 118/76 mm Hg
B. Heart rate 88/min
C. Respiratory rate 8/min
D. Temperature 37.2°C (99°F)
,A nurse is preparing to administer a medication to a client. Which of the following actions
should the nurse take first?
A. Check the client's identification band
B. Verify the medication with a second nurse
C. Administer the medication as prescribed
D. Document the medication administration
, Answer: A. Check the client's identification band
Rationale: The first step in medication administration is to verify the client's identity using
two identifiers, such as the identification band and asking the client to state their name.
A nurse is caring for a client who has a new prescription for a cleansing enema. Which of the
following positions should the nurse place the client in?
A. Supine
B. Left lateral Sims' position
C. Prone
D. High Fowler's
Answer: B. Left lateral Sims' position
Rationale: The left lateral Sims' position allows gravity to help the solution flow into the
colon and promotes retention.
A nurse is performing hand hygiene. Which of the following actions indicates the need for
further teaching?
A. Using alcohol-based hand rub when hands are visibly soiled
B. Washing hands for at least 20 seconds
C. Using soap and water after caring for a client with C. difficile
D. Keeping fingernails short and clean
Answer: A. Using alcohol-based hand rub when hands are visibly soiled
Rationale: Alcohol-based hand rubs are not effective when hands are visibly soiled or
contaminated with blood or body fluids. Soap and water must be used.
A nurse is assessing a client's vital signs. Which of the following findings should the nurse
report immediately?
A. Blood pressure 118/76 mm Hg
B. Heart rate 88/min
C. Respiratory rate 8/min
D. Temperature 37.2°C (99°F)
