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If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?
- A. Time the medication was given
- B. The client's response to the medication
- C. The dose that was administered
- D. Reason for the error
Correct Answer: A
Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.
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A nurse is assessing a client who is 4 hours postoperative following a total hip arthroplasty. Which of the following findings should the nurse report to the provider?
- A. Blood pressure of 118/76 mm Hg
- B. Heart rate of 88/min
- C. Urinary output of 30 mL/hr
- D. Hematocrit 42%
Correct Answer: B
Rationale: The correct answer is B: 'Heart rate of 88/min.' A heart rate of 88/min in a postoperative client can be an early sign of bleeding or other complications. It is essential to report this finding promptly to the healthcare provider for further evaluation and intervention. Choices A, C, and D are within normal ranges for a postoperative client and do not indicate immediate concern. A blood pressure of 118/76 mm Hg is normal, urinary output of 30 mL/hr may be adequate depending on the client's fluid status, and a hematocrit of 42% is within the acceptable range for a postoperative client. Therefore, they do not require immediate reporting.
What is the most effective intervention for a patient experiencing acute pain?
- A. Administer analgesics
- B. Reposition the patient
- C. Provide non-pharmacological interventions
- D. Administer IV fluids
Correct Answer: A
Rationale: Administering analgesics is the most effective intervention for a patient experiencing acute pain as it directly targets the pain receptors and provides relief. Repositioning the patient may help in some cases, but it is not the primary intervention for managing acute pain. Non-pharmacological interventions can be beneficial as adjuncts to pain management but might not provide immediate relief. Administering IV fluids is not a standard intervention for acute pain unless dehydration is contributing to the pain.
A nurse is planning care for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?
- A. Glomerular filtration rate of 14 mL/minute
- B. BUN 16 mg/dL
- C. Serum magnesium 1.8 mg/dL
- D. Serum phosphorus 4.0 mg/dL
Correct Answer: A
Rationale: A glomerular filtration rate of 14 mL/minute indicates severe kidney dysfunction, necessitating hemodialysis. The other options, BUN of 16 mg/dL, serum magnesium of 1.8 mg/dL, and serum phosphorus of 4.0 mg/dL, are within normal ranges and do not serve as indications for hemodialysis.
What is the best way to monitor fluid balance in a patient with kidney disease?
- A. Monitor daily weight
- B. Monitor input and output
- C. Check for edema
- D. Check urine output
Correct Answer: A
Rationale: The correct answer is to monitor daily weight. This method is the most accurate way to assess fluid balance in patients with kidney disease. Daily weight monitoring can detect even small changes in fluid balance, such as fluid retention or loss, which may not be evident through other methods. Monitoring input and output (choice B) is also important but may not provide a complete picture of fluid balance as it doesn't consider factors like insensible losses. Checking for edema (choice C) is a sign of fluid retention but may not always be present or may be difficult to assess accurately. Checking urine output (choice D) is important but may not reflect the overall fluid balance status of the patient.
What is the most appropriate action when a patient is experiencing confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer IV fluids
- D. Perform a neurological exam
Correct Answer: A
Rationale: Administering oxygen is the most appropriate action when a patient is experiencing confusion after surgery because it helps alleviate hypoxia, which may be causing the patient's confusion. Repositioning the patient would not directly address the potential hypoxia issue. Administering IV fluids may be necessary for hydration or other reasons but is not the initial priority in addressing confusion post-surgery. Performing a neurological exam may be important later on to assess the patient's neurological status but should not be the first action taken when confusion is present.