Nokea
A nurse on the orthopedics floor is asked by another nurse to witness her waste 1 mg of morphine. The nurse draws the full 2 mg dose of morphine into the syringe and tells the first nurse, 'This client does not get enough pain relief with 1 mg of morphine, so I just go ahead and give 2 mg to keep him comfortable because the doctor won't change the dose.' Which is the correct action by the first nurse?
- A. tell the other nurse to call the doctor back and request an increase in the dosage
- B. refuse to sign off on the waste and report the incident to the charge nurse or unit manager
- C. sign off the waste, and suggest that the nurse give it over two separate doses 30 minutes apart
- D. sign off the waste, but tell the nurse to give it slowly to be sure that the client can tolerate the dose
Correct Answer: B
Rationale: Administering an unordered dose is a medication error and potential diversion. Refusing to sign and reporting ensures patient safety and accountability.
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The nurse is admitting a client directly from a health provider's office. The client has a rash and has been diagnosed with measles. Which room assignment by the nurse indicates an understanding of the disease process of measles?
- A. a private negative-pressure room
- B. a semiprivate room with a client who has a broken femur
- C. a semiprivate room with a client diagnosed with type 1 diabetes
- D. a private room at the end of the hall away from the nurses' station
Correct Answer: A
Rationale: Measles requires airborne precautions, necessitating a private negative-pressure room to prevent transmission.
A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?
- A. Insert 10 mL of air in the NG tube and listen over the abdomen with a stethoscope
- B. Clamp the tube while listening to the abdomen with a stethoscope
- C. Irrigate the tube with 30 mL of NS while auscultating the abdomen
- D. Turn the suction on high and auscultate over the naval area
Correct Answer: B
Rationale: Clamping the NG tube prevents suction noise from interfering with auscultation, allowing accurate assessment of bowel sounds.
A client was to receive 1 g of vancomycin intravenously in 200 mL of iso-osmotic solution over 60 minutes per infusion pump. However, the IV administration was discontinued after 45 minutes because the client developed nausea and chills. How many milligrams of vancomycin did the client receive? Record your answer using a whole number.
Correct Answer: 750
Rationale: 1 g = 1000 mg in 200 mL over 60 min. In 45 min, 45/60 = 0.75 of dose = 0.75 X 1000 = 750 mg.
The client presents to the emergency room with a hyphema. Which action by the nurse would be best?
- A. Elevate the head of the bed and apply ice to the eye
- B. Place the client in a supine position and apply heat to the knee
- C. Insert a Foley catheter and measure the intake and output
- D. Perform a vaginal exam and check for a discharge
Correct Answer: A
Rationale: Elevating the head and applying ice reduces intraocular pressure and swelling in hyphema, a bleed in the eye.
Which assignment should not be performed by the nursing assistant?
- A. Feeding the client
- B. Bathing the client
- C. Obtaining a stool
- D. Administering a fleet enema
Correct Answer: D
Rationale: Administering an enema is an invasive procedure requiring clinical judgment, which is beyond the scope of a nursing assistant's responsibilities.