Nokea
A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?
- A. The client demonstrated proper technique when drawing up 8 units of insulin
- B. The client stated ‘I struggle to see those little lines on the syringe’
- C. The client FBS was 95 mg/dL
- D. The client seems to be more comfortable performing self-administration of insulin
Correct Answer: D
Rationale: The correct answer is D. The charge nurse should recommend revising this entry because it implies the client is self-administering insulin, which is beyond the scope of practice for a client. This could lead to serious harm if not addressed.
A, B, and C are incorrect because they all indicate proper client care and documentation. A shows proper technique, B indicates client's concern with syringe lines, and C provides the client's fasting blood sugar level.
You may also like to solve these questions
A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing?
- A. Role-play
- B. Question-and-answer
- C. Discussion
- D. Return demonstration
Correct Answer: D
Rationale: The correct answer is D: Return demonstration. This teaching strategy involves the client performing the skill back to the nurse to demonstrate understanding and competence. It allows for immediate feedback and correction. Role-play (A) involves acting out a scenario, not necessarily related to skill demonstration. Question-and-answer (B) involves asking and answering questions but does not involve the client performing a skill. Discussion (C) involves exchanging ideas and opinions, not skill demonstration.
A nurse is teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration?
- A. Trough
- B. Peak
- C. Half-life
- D. Toxic
Correct Answer: A
Rationale: The correct answer is A: Trough. The trough level represents the lowest serum concentration of a medication in the body, usually measured just before the next dose is administered. This is important in monitoring the effectiveness and safety of the drug. Peak levels (B) indicate the highest concentration. Half-life (C) refers to the time it takes for half of the drug to be eliminated from the body. Toxic levels (D) are when the drug concentration is too high and can lead to harmful effects. Other choices are not relevant to the lowest serum concentration.
A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates understanding of body mechanics?
- A. They bend at the hip when lifting
- B. They keep their feet together when lifting an object
- C. They stand close to the object being moved
- D. They twist their spine when lifting
Correct Answer: C
Rationale: The correct answer is C: They stand close to the object being moved. This action indicates understanding of body mechanics as it reduces the strain on the back by keeping the load close to the body's center of gravity. Standing close to the object allows for better leverage and control during the lift, minimizing the risk of injury.
Rationale for why other choices are incorrect:
A: Bending at the hip when lifting can put excessive strain on the lower back.
B: Keeping feet together may lead to instability and lack of balance during lifting.
D: Twisting the spine when lifting can result in spinal injuries and muscle strain.
A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers. Which lab value would the nurse expect to see?
- A. Chloride 112
- B. Calcium 7.5
- C. Potassium 4.0
- D. Calcium 12.1
Correct Answer: B
Rationale: The correct answer is B: Calcium 7.5. With partial removal of the parathyroid gland, there may be decreased production of parathyroid hormone leading to hypocalcemia. Numbness and tingling in the hands and fingers are classic symptoms of hypocalcemia. A low calcium level of 7.5 is indicative of this condition.
Choice A: Chloride 112 is not related to symptoms of numbness and tingling.
Choice C: Potassium 4.0 is within the normal range and not associated with symptoms of hypocalcemia.
Choice D: Calcium 12.1 indicates hypercalcemia, not hypocalcemia, which would not cause numbness and tingling.