Nokea
A nurse is documenting client care including only unexpected findings related to the client's condition. Which of the following documentation methods is the nurse utilizing?
- A. SOAP documentation
- B. Focus charting (DAR)
- C. Charting by exception (CBE)
- D. Problem-oriented medical record (POMR)
Correct Answer: C
Rationale: Charting by exception (CBE) is the correct answer. CBE involves documenting only significant findings or exceptions to the norm. This method focuses on deviations from the expected baseline, promoting efficiency and highlighting important changes in the client's condition. By documenting unexpected findings related to the client's condition, the nurse is using CBE to streamline the documentation process and prioritize critical information. SOAP documentation (A) involves subjective, objective, assessment, and plan format, which is more comprehensive. Focus charting (DAR) (B) focuses on data, action, and response but does not specifically target unexpected findings. Problem-oriented medical record (POMR) (D) emphasizes problem lists, making it less focused on exceptions.
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A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include?
- A. Provide a dedicated area for the nurse to prepare medications
- B. Wait to document medications given to clients until the end of a shift
- C. Remove medications from automatic dispensing systems before they are reviewed by pharmacists
- D. Prepare medications for multiple clients at the same time
Correct Answer: A
Rationale: Correct Answer: A - Provide a dedicated area for the nurse to prepare medications.
Rationale: Providing a dedicated area for medication preparation helps reduce distractions and promotes focus, decreasing the likelihood of errors. This setup allows for organization and prevents cross-contamination. It also encourages proper storage and disposal of medications, fostering a safer environment for medication preparation.
Summary of Other Choices:
B: Waiting to document medications until the end of a shift can lead to errors in documentation and potential confusion. Real-time documentation is crucial for accuracy.
C: Removing medications from automatic dispensing systems before pharmacist review bypasses a critical safety check, increasing the risk of errors.
D: Preparing medications for multiple clients simultaneously can lead to mix-ups and errors, as it increases the chances of confusion and incorrect dosing.
A nurse is preparing to administer digoxin 5 mg PO to a client. The amount available is digoxin 0.5 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 10
Rationale: The correct answer is 10 tablets. To calculate, you divide the total dose needed (5 mg) by the dose per tablet (0.5 mg). 5 mg ÷ 0.5 mg = 10 tablets. The nurse should administer 10 tablets of digoxin to achieve the desired 5 mg dose. Other choices are incorrect because they do not result in the correct dosage amount required for the client.
A nurse is taking care of a patient that has a new prescription for labetalol (beta blocker). What adverse effect should the nurse include in the medication education?
- A. Hypokalemia
- B. Bleeding
- C. Bradycardia
- D. Seizures
Correct Answer: C
Rationale: The correct answer is C: Bradycardia. Labetalol is a beta blocker that slows down the heart rate by blocking beta-adrenergic receptors. This can lead to bradycardia, which is a slow heart rate. The nurse should educate the patient about this potential adverse effect to prevent any complications.
Hypokalemia (choice A) is not a common adverse effect of labetalol. Bleeding (choice B) is not directly associated with beta blockers like labetalol. Seizures (choice D) are not a typical adverse effect of labetalol. Therefore, the correct answer is C as it directly correlates with the mechanism of action of labetalol.
A nurse is receiving report on a group of clients. Using the ABCDE priority framework which of the following clients should the nurse see first?
- A. A client who has early dementia and awoke confused to their location this morning
- B. A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning
- C. A client who has pneumonia and has developed wheezing
- D. A client who is postoperative and has a urine output of 50 mL for the past 3 h
Correct Answer: C
Rationale: The correct answer is C because the client with pneumonia developing wheezing is experiencing a potential airway obstruction, impacting their breathing (airway). In the ABCDE priority framework, airway comes first to ensure adequate oxygenation. Choice A may indicate confusion but does not pose an immediate threat to life. Choice B has a fever, but unless there are other concerning symptoms, it does not require immediate attention. Choice D has decreased urine output, indicating a potential issue with circulation or kidneys, but it is not immediately life-threatening. Therefore, C takes precedence due to the potential airway compromise.
A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take?
- A. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading
- B. Place the sensor probe on the same extremity as an electronic blood pressure cuff
- C. Relocate the sensor every 8 hrs
- D. Choose a finger with a capillary refill less than 2 sec
Correct Answer: D
Rationale: The correct answer is D: Choose a finger with a capillary refill less than 2 sec. This is important because a capillary refill time longer than 2 seconds may indicate poor circulation, which can affect the accuracy of the oxygen saturation reading. It ensures proper blood flow to the finger, leading to a more reliable measurement. Waiting 10 seconds before obtaining the reading (A) is unnecessary and may delay timely intervention. Placing the sensor probe on the same extremity as an electronic blood pressure cuff (B) can interfere with accurate readings. Relocating the sensor every 8 hours (C) is not necessary for routine monitoring and may disrupt continuous monitoring.