Nokea
During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take?
- A. Do not continue the handoff report with the oncoming nurse
- B. Document the incident according to facility policy
- C. Notify the charge nurse
- D. Say nothing but watch for impaired behavior
- E. Tell the oncoming nurse that he/she is not fit for duty
Correct Answer: B,C
Rationale: Notifying the charge nurse (C) and documenting (B) ensure patient safety and follow protocol. Stopping handoff (A) disrupts care continuity. Watching silently (D) delays action, and confronting directly (E) may escalate the situation.
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The nurse is caring for a newborn with patent ductus arteriosus. Which finding would be consistent with the condition?
- A. Blowing diastolic murmur
- B. Harsh systolic murmur
- C. Loud machine-like murmur
- D. Systolic ejection murmur
Correct Answer: C
Rationale: Patent ductus arteriosus causes a loud, machine-like murmur (C) due to continuous blood flow. Other murmurs (A, B, D) are associated with different cardiac conditions.
The nurse is caring for a client receiving treatment for benign prostatic hyperplasia. Which client statement requires further investigation?
- A. I have a burning sensation when I urinate.
- B. I have been having some dribbling after I finish urinating.
- C. I missed 3 days of finasteride while on a trip last week.
- D. I was awakened 3 times last night by the need to urinate.
Correct Answer: A
Rationale: Burning on urination (A) suggests a urinary tract infection, requiring investigation. Dribbling (B), nocturia (D), and missing doses (C) are common with BPH or medication non-adherence but less urgent.
The client with a colostomy does not feel that the irrigating solution has drained completely. The nurse can enhance the effectiveness of the colostomy irrigation by telling the client to:
- A. Massage the abdomen gently.
- B. Reduce the amount of irrigation solution.
- C. Increase his oral intake.
- D. Place a heating pad on the abdomen.
Correct Answer: A
Rationale: Gentle abdominal massage can stimulate peristalsis and help the irrigation solution drain completely from the colostomy. Reducing solution or using a heating pad is not standard, and increasing oral intake is unrelated.
The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective?
- A. I need to continue to avoid eating spinach and kale.
- B. I probably will have some weakness in my legs when I take this medicine.
- C. I should avoid taking aspirin while receiving this medication.
- D. I will have to get blood drawn routinely to check my clotting levels.
Correct Answer: C
Rationale: Rivaroxaban is a direct oral anticoagulant that does not require routine monitoring of clotting levels, unlike warfarin. It also does not necessitate dietary restrictions like avoiding spinach and kale, which are relevant for warfarin due to vitamin K interactions. Avoiding aspirin is correct because it increases bleeding risk when combined with rivaroxaban. Weakness in legs is not a typical side effect of rivaroxaban.
The nurse is caring for a newly admitted man who has kidney stones. The man asks if he can get up and take a walk. How should the nurse respond?
- A. It is better for you to remain in bed until the stones pass.'
- B. Stay in bed until I check with your physician.'
- C. Walking is good for you. Let me help you up.'
- D. It is safe for you to ambulate once a day.'
Correct Answer: C
Rationale: Walking may facilitate kidney stone passage and is generally safe unless contraindicated, with assistance ensuring safety.