Nokea
The nurse fails to recognize that a client's vital signs have deteriorated over the past 4 hours after surgery. Later, the client requires emergency surgery. Which legal consequence does the nurse potentially face because of a failure to act?
- A. Tort
- B. Statutory law
- C. Common law
- D. Misdemeanor
Correct Answer: A
Rationale: The nurse's inaction is consistent with a tort offense because a tort is a wrongful act intentionally or unintentionally committed against a person or the person's property. Option 2 describes laws that are enacted by state, federal, or local governments. Option 3 describes case law that has evolved over time via precedents. Option 4 is an offense under criminal law.
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A client with a history of cirrhosis is admitted with ascites. The nurse should include which of the following in the plan of care?
- A. Administer spironolactone as prescribed.
- B. Restrict sodium intake.
- C. Encourage a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A, B
Rationale: Spironolactone and sodium restriction reduce fluid retention in ascites.
The nurse is caring for a client with a history of deep vein thrombosis (DVT) who is receiving heparin. The nurse should monitor the client for which of the following laboratory values?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. Platelet count.
Correct Answer: A, D
Rationale: Heparin is monitored with aPTT for therapeutic effect and platelet count for heparin-induced thrombocytopenia.
The nurse teaches a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client has a need for further teaching if the client makes which statement?
- A. An anesthetic throat spray will be used.
- B. A signed informed consent is necessary.
- C. Medication will be given orally for sedation.
- D. It is important to lie still during the procedure.
Correct Answer: C
Rationale: Intravenous sedation (not oral) is given to relax the client, and an anesthetic throat spray is used to help keep the client from gagging as the endoscope is passed. The client has to sign an informed consent form. The client also needs to lie still for ERCP, which takes about an hour to perform.
You have been conducting a weekly outpatient stress management educational series for clients in the community who are hypertensive. The best way to evaluate the effectiveness of this educational series is to:
- A. Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data during the series and after the series is completed.
- B. Collect baseline blood pressure readings prior to the beginning of this educational series and then collect and compare blood pressure data after the series is completed.
- C. Ask the clients how often they use the stress management techniques that they have learned during this educational series.
- D. Use a questionnaire at the end of the series that asks the participants how they liked the class and what they learned during this educational series.
Correct Answer: A
Rationale: Collecting and comparing blood pressure data before, during, and after the series provides objective evidence of the program's effectiveness in managing hypertension.
The nurse is planning care for a client with a chest tube attached to a chest drainage system. Which actions should the nurse include as part of routine chest tube care? Select all that apply.
- A. Encourage the client to cough and deep breathe.
- B. Add water to the suction chamber as it evaporates.
- C. Keep the collection chamber below the client's waist.
- D. Clamp the chest tube when the client gets out of bed.
- E. Tape the connection between the chest tube and the drainage system.
Correct Answer: A,B,C,E
Rationale: The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection. To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy.