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A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
- A. An incident report has been completed and sent to risk management.
- B. Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom.'
- C. The client fell because the assistive personnel did not place nonskid slippers on the client.
- D. The client does not appear to have any injuries resulting from the fall.
Correct Answer: B
Rationale: Documenting the client's statement provides an accurate account of the incident. Incident reports, blame, or injury absence are inappropriate for the medical record.
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A nurse is caring for a client who is receiving IV vancomycin. Which of the following actions should the nurse take?
- A. Infuse the medication over 30 min.
- B. Monitor the client for tinnitus.
- C. Administer the medication with an antihistamine.
- D. Check the client's blood pressure every 4 hr.
Correct Answer: B
Rationale: Vancomycin can cause ototoxicity, so monitoring for tinnitus is essential. It's infused over 60-90 minutes, antihistamines aren't needed, and blood pressure checks aren't specific to vancomycin.
A nurse is caring for a client who is receiving IV chemotherapy. Which of the following actions should the nurse take?
- A. Check the IV site for redness or swelling.
- B. Administer the chemotherapy through a peripheral IV line.
- C. Monitor the client's blood pressure every 4 hr.
- D. Instruct the client to avoid drinking water during infusion.
Correct Answer: A
Rationale: Checking for redness or swelling detects extravasation early, critical for chemotherapy safety. Central lines are preferred, blood pressure checks are routine, and hydration is encouraged.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?
- A. The client's blood glucose is 120 mg/dL.
- B. The client's temperature is 38.3°C (100.9°F).
- C. The client's weight increased by 0.5 kg overnight.
- D. The client reports mild discomfort at the IV site.
Correct Answer: B
Rationale: A temperature of 38.3°C suggests infection, possibly catheter-related, requiring reporting. Normal glucose, slight weight gain, and mild discomfort are less urgent.
A nurse is reinforcing teaching with a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include?
- A. Take this medication in the morning.
- B. You might experience muscle pain while taking this medication.
- C. You need to avoid grapefruit juice while taking this medication.
- D. You should stop taking this medication if you feel dizzy.
Correct Answer: B,C
Rationale: Simvastatin can cause myopathy (muscle pain) and interacts with grapefruit juice, increasing toxicity risk. It's taken at night, and dizziness doesn't warrant stopping.
A nurse is caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take to prevent infection?
- A. Encourage the client to avoid fresh fruits and vegetables.
- B. Administer prophylactic antibiotics daily.
- C. Monitor the client's white blood cell count regularly.
- D. Instruct the client to avoid crowded places.
Correct Answer: C
Rationale: Monitoring WBC counts detects neutropenia early, guiding infection prevention. Fresh produce is safe if washed, antibiotics aren't routine, and avoiding crowds is secondary.