Nokea
A nurse indicates that she is licensed in her new state of residence even though reciprocity has not been granted. The nurse’s action can result in a charge of:
- A. Fraud
- B. Tort
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: Claiming licensure without reciprocity is a deliberate misrepresentation, constituting fraud. A tort is a civil wrong, malpractice involves substandard care, and negligence implies carelessness, none of which fully describe this intentional act.
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On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
- A. Administer her next dosage of lithium, and then call the physician.
- B. Withhold her lithium, and report her symptoms to the physician.
- C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
- D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
Correct Answer: B
Rationale: The client has lithium toxicity, and the nurse must withhold further dosages. Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level.
In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:
- A. Explain the side effects of the medication
- B. Discuss the danger of overmedication
- C. Distribute written material to supplement verbal instructions
- D. Explore the client's perception regarding medication therapy
Correct Answer: D
Rationale: (A, B, C) The nurse must first obtain information regarding the client's perception of the medication regimen. The first step in the teaching process is to determine the client's perception.
A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
- A. Just before sun exposure
- B. Five minutes before sun exposure
- C. 15 minutes before sun exposure
- D. 30 minutes before sun exposure
Correct Answer: D
Rationale: Chemical sunscreens require 30 minutes to absorb into the skin for optimal UV protection. Applying closer to exposure reduces effectiveness.
Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
- A. Oxygen saturation
- B. Respiratory rate
- C. Breath sounds
- D. Arterial blood gases
Correct Answer: C
Rationale: Adventitious breath sounds (e.g., rhonchi, wheezing) indicate mucus obstruction, signaling the need for suctioning. Oxygen saturation, respiratory rate, and ABGs are less specific.
The nurse is caring for a client with a diagnosis of preterm labor. Which medication is most likely to be ordered?
- A. Betamethasone
- B. Terbutaline
- C. Magnesium sulfate
- D. All of the above
Correct Answer: D
Rationale: Betamethasone promotes fetal lung maturity terbutaline and magnesium sulfate are tocolytics to halt preterm contractions and magnesium may also provide neuroprotection. All are commonly ordered in preterm labor.