Nokea
During the change of shift, the oncoming nurse notes a discrepancy in the number of percocette listed and the number present in the narcotic drawer. The nurse's first action should be to:
- A. Notify the hospital pharmacist
- B. Notify the nursing supervisor
- C. Notify the Board of Nursing
- D. Notify the director of nursing
Correct Answer: B
Rationale: A narcotic discrepancy requires reporting to the supervisor for investigation.
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A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: facilitates swallowing and movement of tube through GI tract
The nurse is assessing a client with suspected dehydration. Which of the following findings would the nurse expect?
- A. Bradycardia and hypertension.
- B. Dry mucous membranes and tented skin.
- C. Clear, dilute urine.
- D. Increased respiratory rate.
Correct Answer: B
Rationale: dry mucous membranes and tented skin are signs of dehydration due to fluid loss
According to Erikson's stages of physical development, school-age children 5 - 12 years old typically face which psychological crisis?
- A. ego integrity versus despair
- B. industry versus inferiority
- C. trust versus mistrust
- D. ego identity versus role confusion
Correct Answer: B
Rationale: School-age children (5-12) face industry vs. inferiority, focusing on developing competence and self-esteem through tasks and skills.
One week after discharge of a postpartum client, the client's husband calls the postpartum unit and asks the nurse, 'Is it normal for my wife to cry at the drop of a hat? I'm worried I've done something to upset her.' The nurse's best initial response would be:
- A. Have you noticed any pattern to her periods of crying?
- B. Try not to worry about it. I'm sure it's just the postpartum blues.
- C. Can you think of something you might have done to upset her?
- D. Let's consider some of the ways you can decrease her depression.
Correct Answer: B
Rationale: Postpartum blues are common within the first two weeks, characterized by emotional lability. Reassuring the husband while acknowledging the normalcy of this condition is appropriate.
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- A. Oral mucous membrane, altered related to chemotherapy
- B. Risk for injury related to thrombocytopenia
- C. Fatigue related to the disease process
- D. Interrupted family processes related to life-threatening illness of a family member
Correct Answer: B
Rationale: Thrombocytopenia in acute leukemia increases the risk of bleeding, making 'risk for injury' the priority diagnosis to ensure patient safety.