Nokea
The charge nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be charged with:
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: C
Rationale: Hitting a client is assault, a criminal act of physical harm.
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A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push. The nurse should withhold the next dose of this medication and notify the physician if which of the following is observed on the cardiac monitor?
- A. One premature ventricular contraction (PVC).
- B. Sinus rhythm with occasional bigeminy.
- C. Persistent tachycardia of 112 beats per minute.
- D. Prolongation of the QT interval.
Correct Answer: D
Rationale: prolongation of the QT interval is a side effect that can lead to torsades de pointes, a life-threatening arrhythmia
The nurse is caring for a first-time mother who is asking how to help her baby sleep through the night as the baby gets older. Which recommendation should the nurse tell the mother?
- A. Rock her to sleep every night until she is in a deep sleep.
- B. Give diphenhydramine 12.5 mg orally to put the baby to sleep.
- C. If she starts waking up a lot in the middle of the night, put her in the bed with you.
- D. Give the last feeding as late as possible, and put her in the bed awake without a bottle.
Correct Answer: D
Rationale: Placing the baby in bed awake after a late feeding promotes self-soothing and healthy sleep habits, unlike the other options, which may create dependencies or safety risks.
The nurse should explain to a client that tolbutamide (Orinase) is effective for diabetics who
- A. can no longer produce any insulin.
- B. produce minimal amounts of insulin.
- C. are unable to administer their injections.
- D. have a sustained decreased blood glucose.
Correct Answer: B
Rationale: oral hypoglycemic agents are administered to type II (non-insulindependent) clients who are able to produce minimal amounts of insulin
The nurse is assessing for abdominal pulsations in a client with a visible mass below the umbilicus. The nurse should use which technique?
- A. light palpation
- B. inspection
- C. percussion
- D. deep palpation
Correct Answer: B
Rationale: Inspection is used to visually assess for abdominal pulsations or masses. Palpation or percussion may be used later but are not the initial technique for observing pulsations.
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
- A. Serum collection (Davol) drain
- B. Client's pain
- C. Nutritional status
- D. Immobilizer
Correct Answer: B
Rationale: Pain assessment is a priority post-surgery to manage discomfort and detect complications.