You are on page 1of 5

1. A client tells the nurse, This pill is a different color than the one that I usually take at home.

. Which is the
best response by the nurse?
a. The doctor ordered a different medication Review the chart to make sure there is no discrepancy
between the physicians order and the MAR. Review the physicians progress notes because the
medication may have been increased or reduced as part of the treatment plan
b. Go ahead and take your medicine do not administer the medication
c. Ill leave the pill here while I check with the doctor Do not leave the medications at bedside,
Medications should never be left unattended.
d. I will recheck your medication Inform the client of your findings. The client will appreciate that
you took the time to make sure that he/she received the correct medication. While it takes time to
check out the clients statement, you will be glad that you avoided a potential medication error

2. Pressume that the full name of the client, the date and time that the order was written, and the physicians
signature are present on the physicians order sheet. The following medications are listed on the MAR. Which
would you question?
a. Lasix 40mg, po, STAT Lasix 40 mg by mouth immediately
b. Ampicillin 500 mg q 6 hr, IVPB Ampicillin 500 mg every 6 hours Intravenous Piggy Back
c. Humulin L (Lente) insulin 36 u, sc, q am, ac Humulin Lente insulin 36 units subcutaneously every
morning before breakfast. (ac = ante cibum)
d. Codeine q 4-6hr, po, PRN for pain Codeine every 4-6hr taken by mouth as needed dosage is

Contents of MAR
The actual chart varies from hospital to hospital and country to country. However they are typically of the format:
Patient Name (often Surname, First name or
Patient Medical Record Number
Ward +/- bed number
Treating team details
Other, variable - weight, special diet, oxygen
therapy, application time of topical local
anaesthetic e.g. EMLA
Prescription Details
Drug name
Dosage strength
Medication indication / Diagnosis
Prescribing doctor details, signature
Day by day chart
where carers/nurses administering medications
can sign when medication has been given

3. The nurse plans to remove the clients sutures. Which of the following actions demonstrate
appropriate standards of care?
1. Use of clean technique sterile technique
2. Grasp the suture at the knot with a pair of forceps
3. Place the curved tip of the suture scissors under the suture as close to
the skin as possible
4. Pull the suture material that is visible beneath the skin during removal
below the skin level
5. Remove alternate sutures first
a. 1, 2, 4
b. 2, 3, 5
c. 1, 2, 3, 4
d. 1, 2, 3, 4, 5

Removal of sutures
1. Check if your facility allows you to do removal of sutures
2. Check for patients allergies (adhesive tapes, povidone-iodine, others topical meds or other
3. Tell the patient that youre going to remove the stitches from his wound. Assure that it is
typically painless, wound is healing properly, removing stitches wont weaken the incision
4. Provide privacy and position comfortably
5. Wash hands thoroughly
6. Observe wound for possible gapping, drainage, inflammation, signs of infection, and embedded
7. Establish sterile work area
8. Use sterile technique, clean suture line
9. Use of sterile forceps, grasp the knot of the first suture and raise it off the skin will expose a
small portion of the suture that was below skin level
10. Place the rounded tip of sterile curved-tip suture scissors against the skin, and cut through the
exposed portion of the suture
11. Then, still holding the knot with the forceps, pull the cut suture up and out of the skin in a
smooth continuous motion to avoid causing the patient pain
12. Discard the suture
13. Repeat process for every other suture
14. After removing sutures, wipe the incision gently with gauze pads soaked in an antiseptic
cleaning agent or with a povidone-iodine pad. Apply la light sterile gauze dressing, if needed , to
prevent infection and irritation from clothing. The discard your gloves
15. Make sure the patient is comfortable
16. Proper dispose of the solutions and trash bag, and clean or dispose of soiled equipments and
supplies according to your facilitys policy.

4. A client with impaired vision is admitted to the hospital. Which interventions are most
appropriate to meet the clients needs?
1. Identify yourself by name
2. Decrease background noise before speaking Hearing deficit
3. Stay in the clients field of vision
4. Explain the sounds in the environment
5. Keep your voice at the same level throughout the conversation
hearing deficit
a. 1, 3, 5
b. 2, 3, 4
c. 1, 3, 4
d. 1, 2, 3, 4, 5

Always announce your presence when entering the client's room and identify yourself by name,
Stay in the client's field of vision if the client has a partial vision loss,
Speak in a warm and pleasant tone of voice. Some people tend to speak louder than necessary
when talking to a blind person.
Always explain what you are about to do before touching the person.
Explain the sounds in the environment.
Indicate when the conversation has ended and when you are leaving the room.

Before initiating conversation, convey your presence by moving to a position where you can be
seen or by gently touching the person.
Decrease background noises (e.g., television) before speaking,
Talk at a moderate rate and in a normal tone of voice. Shouting does not make your voice more
distinct and in some instances makes understanding more difficult
Address the person directly. Do not turn away in the middle of a remark or story. Make sure the
person can see your face easily and that it is well lighted.
Avoid talking when you have something in your mouth, such as chewing gum. Avoid covering
your mouth with your hand
Keep your voice at about the same volume throughout each sentence, without dropping the
voice at the end of each sentence,
Always speak as clearly and accurately as possible. Articulate consonants with particular care.
Do not "overarticula te"; mouthing or overdoing articulation is just as troublesome as
mumbling. Pantomime or write ideas, or use sign language or finger spelling as appropriate.
Use longer phrases, which tend to be easier to understand than short ones. For example,
"Would you like a drink of water?" presents much less difficulty than "Would you like a drink?"
Word choice is important: "Fifteen cents" and "fifty cents" may be confused, but "half a dollar"
is clear.
Pronounce every name with care. Make a reference to the name for easier understanding, for
example, "Joan, the girl from the office" or "Sears, the big downtown store."
Change to a new subject at a slower rate, making sure that the person follows the change to the
new subject. A key word or two at the beginning of a new topic is a good indicator.

5. A client is exhibiting signs and symptoms of acute confusion or delirium. The nurse implements
which of the following strategies to promote a therapeutic environment?
1. Keep the lights in the room dimmed to reduce stimulation
2. Keep the environmental noise level high to increase stimulation
3. Keep the room organized and clean
4. Use restraints for client safety.
5. Schedule activities at the same time each day
a. 1 and 5
b. 2 and 4
c. 3 and 5
d. 1 and 3

Promoting a Therapeutic Environment for a Client with Acute Confusion/Delirium
Wear a readable name tag.
Address the person by name and introduce yourself frequently: "Good morning, Mr. Richards. I
am Betty Brown. I will be your nurse today."
Identify time and place as indicated: "Today is December 5, and it is 8:00 in the morning."
Ask the client, "Where are you?" and orient the client to place (e.g., nursing home) if indicated.
Place a calendar and clock in the client's room. Mark holidays with ribbons, pins, or other
Speak clearly and calmly to the client, allowing time for your words to be processed and for the
client to give a response.
Encourage family to visit frequently except if this activity causes the client to become
Provide clear, concise explanations of each treatment procedure or task.
Eliminate unnecessary noise.
Reinforce reality by interpreting unfamiliar sounds, sights, and smells; correct any
misconceptions of events or situations.
Schedule activities (e.g., meals, bath, activity and rest periods, treatments) at the same time
each day to provide a sense of security. If possible, assign the same caregivers.
Provide adequate sleep.
Keep glasses and hearing aid within reach.
Ensure adequate pain management.
Keep familiar items in the client's environment (e.g., photographs), and keep the environment
uncluttered. A disorganized, cluttered environment increases confusion.
Keep room well lit during waking hours.