Nokea
A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching?
- A. ''OOB with assistance for breakfast''
- B. ''Given 2 mg MSO4 IM for report of pain''
- C. ''Dressing changed qd''
- D. ''Administered 8 units of regular insulin subcutaneously''
Correct Answer: D
Rationale: The correct answer demonstrates proper documentation by specifying the action taken ('Administered'), the dose ('8 units'), the medication ('regular insulin'), and the route of administration ('subcutaneously'). This notation ensures clarity and accuracy in recording the nursing intervention, aligning with best practices in documentation.
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A healthcare professional is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the healthcare professional expect?
- A. Increased creatinine.
- B. Increased hemoglobin.
- C. Increased bicarbonate.
- D. Increased calcium.
Correct Answer: A
Rationale: In chronic kidney disease, the kidneys are unable to effectively filter waste products from the blood, leading to an accumulation of creatinine. Creatinine levels are commonly elevated in individuals with impaired kidney function, making it a key indicator of kidney health. Therefore, an increased creatinine level would be an expected finding in a client with chronic kidney disease.
A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Urine output of 20 ml/hr.
- B. Montevideo units constantly at 300 mm Hg.
- C. FHR pattern showing absent variability.
- D. Contractions occurring every 5 minutes and lasting 30 seconds.
Correct Answer: B
Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.
A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?
- A. Notify the provider.
- B. Report the incident to the healthcare facility's manager.
- C. Monitor vital signs.
- D. Fill out an incident report.
Correct Answer: C
Rationale: In a situation where the wrong medication has been administered to a client, the immediate priority is to assess and monitor the client's vital signs to identify any adverse effects of the incorrect medication. This action takes precedence over notifying the provider, reporting the incident, or filling out an incident report. Monitoring vital signs allows for timely recognition and intervention if the client experiences any negative reactions to the wrong medication, ensuring their safety and well-being.
A client is being assessed by a nurse who is 30 minutes postoperative following an arterial thrombectomy. Which of the following findings should the nurse report?
- A. Chest pain
- B. Muscle spasms
- C. Cool, moist skin
- D. Incisional pain
Correct Answer: A
Rationale: Chest pain is a critical finding postoperatively, especially after an arterial thrombectomy, as it could indicate complications like myocardial infarction or pulmonary embolism. It requires immediate attention and further evaluation. Muscle spasms, cool moist skin, and incisional pain are important to assess but not as urgent as chest pain in this scenario.
A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy?
- A. Teaching parenting skills to expectant mothers and their partners.
- B. Conducting mental health screenings at the local community center
- C. Referring clients with obesity to community exercise programs
- D. Providing crisis intervention through a mobile counseling unit
Correct Answer: A
Rationale: The correct answer is teaching parenting skills to expectant mothers and their partners. This intervention is a primary prevention strategy aimed at educating individuals before a problem or condition develops. By teaching parenting skills, the nurse is promoting healthy behaviors and relationships, which can prevent future issues. The other options involve secondary or tertiary prevention strategies by identifying and treating existing conditions or providing interventions after a problem has occurred.