Nokea
The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: D
Rationale: Malpractice involves professional negligence causing harm, as in administering an incorrect dose of medication.
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The nurse is teaching a client with limited mobility about preventing blood clots. Which statement by the nurse is correct?
- A. Do not cross your legs when sitting.
- B. Avoid riding in a car for more than two hours.
- C. Put a pillow under your knees when lying in bed.
- D. You should ask your doctor to give you a blood thinner.
Correct Answer: A
Rationale: Crossing legs can impede venous return, increasing clot risk, so avoiding this is correct. Long car rides are a risk but not limited to two hours, and pillows under knees can worsen circulation.
A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:
- A. Providing a calm environment
- B. Obtaining a diet history
- C. Administering an analgesic
- D. Assessing fetal heart tones
Correct Answer: D
Rationale: Severe hypertension (180/96) poses a risk to fetal well-being, prioritizing fetal heart tone assessment.
A client recently diagnosed with atrial fibrillation is being discharged home on digoxin (Lanoxin). The nurse is providing education to the client and family. Which client statement indicates the need for further teaching?
- A. I should take my medicine at the same time each day.
- B. If I miss a dose, I can take it as soon as I remember it.
- C. I need to call my doctor if my heart rate goes below 60 or above 110.
- D. Changes in my vision could be toxicity and should be reported immediately.
Correct Answer: B
Rationale: Taking a missed digoxin dose as soon as remembered is incorrect; clients should skip it if it’s close to the next dose to avoid toxicity. Other statements reflect correct understanding.
A 65-year-old client who recently retired from many years of working full-time for a company has become increasingly unmotivated and states he feels as though he has no purpose. Which of the following recommendations are most appropriate? Select all that apply.
- A. Volunteer or get a part-time job.
- B. Participate in community activities.
- C. Join a senior citizen's group.
- D. Be thankful he can afford to retire.
- E. Ask to have retirement reversed.
Correct Answer: A,B,C
Rationale: Volunteering/part-time work (A), community activities (B), and senior groups (C) provide purpose. Gratitude (D) is dismissive, and reversing retirement (E) is impractical.
A client with Alzheimer's disease has been prescribed donepezil (Aricept). Which information should the nurse include in the teaching plan for a client on Aricept?
- A. Take the medication with meals.'
- B. The medicine can cause dizziness, so rise slowly.'
- C. If a dose is skipped, take two the next time.'
- D. The pill can cause an increase in heart rate.'
Correct Answer: B
Rationale: Donepezil can cause dizziness due to its cholinergic effects, so clients should rise slowly to prevent falls. It's taken at bedtime, not with meals, and doses shouldn't be doubled.