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The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the physician, the nurse fills out an incident report. Which of the following is the nurse's next action?
- A. Give the incident report to the nurse-manager.
- B. Place the incident report on the chart.
- C. Call the family to inform them.
- D. Omit mentioning the fall in the chart documentation.
Correct Answer: A
Rationale: The incident report should be given to the nurse-manager for review and follow-up, as it is an internal document for quality improvement, not part of the medical record.
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The nurse-manager on the medical unit is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.
- A. Admission to the hospital.
- B. Transfer to the nursing home.
- C. Transfer of a client from surgery to the surgical unit.
- D. Admission to a home health agency from the hospital.
- E. Move from a double room to a single room on the same unit.
Correct Answer: A,B,C,D
Rationale: Medication reconciliation is required during transitions of care (admission, transfers, discharge to home health) to ensure accuracy. Moving rooms on the same unit does not typically require reconciliation.
What is the expected date of delivery for your pregnant client when her last menstrual period was on 10/20/2016?
- A. 7/7/2017
- B. 8/7/2017
- C. 6/7/2017
- D. 8/1/2017
Correct Answer: A
Rationale: Using Naegele's rule, add 1 year and 7 days to the first day of the last menstrual period (10/20/2016), then subtract 3 months: 10/20/2016 + 1 year = 10/20/2017, + 7 days = 10/27/2017, - 3 months = 7/27/2017. Adjusting for a standard 40-week gestation, the expected delivery date is approximately 7/7/2017.
A client with a history of heart failure is prescribed torsemide (Demadex). The nurse should monitor the client for which of the following adverse effects?
- A. Hypokalemia.
- B. Hypernatremia.
- C. Hypermagnesemia.
- D. Hypercalcemia.
Correct Answer: A
Rationale: Torsemide, a loop diuretic, can cause hypokalemia.
The nurse monitors the serum electrolyte levels of a client who is taking digoxin (Lanoxin). Which of the following electrolyte imbalances is a common cause of digoxin toxicity?
- A. Hyponatremia.
- B. Hypomagnesemia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: Hypokalemia enhances digoxin's effect on the heart, increasing toxicity risk by altering cardiac membrane potential.
A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment?
- A. Inability to move toes.
- B. Cyanosis of toes.
- C. Complaints of cast tightness.
- D. Tingling of toes.
Correct Answer: D
Rationale: Tingling is an early sign of circulatory impairment due to nerve compression from swelling or tight casting, requiring prompt attention.