Nokea
A nurse who has been named in a lawsuit can use which of these factors for the best protection in a court of law?
- A. Clinical specialty certification in the associated area of practice
- B. Documentation on the specific client record with a focus on the nursing process
- C. Yearly evaluations and proficiency reports prepared by nurse's manager
- D. Verification of provider's orders for the plan of care with identification of outcomes
Correct Answer: B
Rationale: Documentation is the key to protect nurses when a lawsuit is filed. The thorough documentation should include all steps of the nursing process - assessment, analysis, plan, intervention, evaluation.
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The client is exhibiting multifocal premature ventricular contractions. Which antidysrhythmic medication should the nurse anticipate the HCP ordering for this dysrhythmia?
- A. Adenosine.
- B. Epinephrine.
- C. Atropine.
- D. Amiodarone.
Correct Answer: D
Rationale: Amiodarone is effective for ventricular dysrhythmias like PVCs, per ACLS guidelines. Adenosine, epinephrine, or atropine are used for other rhythms.
A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
- A. Ask client to cough sputum into container
- B. Have the client take several deep breaths
- C. Provide an appropriate specimen container
- D. Assist with oral hygiene
Correct Answer: D
Rationale: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this first action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.
The client with postmenopausal osteoporosis is prescribed the bisphosphonate alendronate (Fosamax). Which discharge instruction should the nurse discuss with the client?
- A. The medication must be taken with the breakfast meal only.
- B. Remain upright for at least 30 minutes after taking medication.
- C. The tablet should be chewed thoroughly before swallowing.
- D. Stress the importance of having monthly hormone levels.
Correct Answer: B
Rationale: Alendronate requires upright posture for 30 minutes post-dose to prevent esophageal irritation, per FDA guidelines. Meal timing, chewing, or hormone levels are incorrect.
The client is complaining of nausea, and the nurse administers the antiemetic promethazine (Phenergan), IVP. Which intervention has priority for this client after administering this medication?
- A. Instruct the client to call the nurse before getting out of bed.
- B. Evaluate the effectiveness of the medication.
- C. Assess the client's abdomen and bowel sounds.
- D. Tell the client not to eat or drink for at least one (1) hour.
Correct Answer: A
Rationale: Promethazine causes sedation and orthostatic hypotension; instructing to call before ambulating prevents falls, the priority post-IVP.
The 68-year-old client is admitted to the emergency department with complaints of slurred speech, right-sided weakness, and ataxia. The emergency department physician ordered thrombolytic therapy for the client. Which action should the nurse implement first?
- A. Administer thrombolytic therapy via protocol.
- B. Send the client for a STAT CT of the head.
- C. Arrange for admission to the intensive care department.
- D. Check to determine if the client is cross sensitive to the thrombolytic.
Correct Answer: B
Rationale: A STAT head CT rules out hemorrhagic stroke, a contraindication for thrombolytics, and is the first step per stroke guidelines.