Nokea
The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time?
- A. 1700
- B. 1710
- C. 1740
- D. 1810
Correct Answer: C
Rationale: Without specific exhibit details, 1740 is assumed incorrect based on context, possibly due to a documentation error related to the fall. Rationale is limited without exhibit.
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An RN from the women's health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse?
- A. A newly diagnosed client with type 2 diabetes mellitus who is learning foot care
- B. A client from a motor vehicle accident with an external fixation device on the leg.
- C. A client admitted for a barium swallow after a transient ischemic attack
- D. A newly admitted client with a diagnosis of pancreatic cancer
Correct Answer: B
Rationale: This client is the most stable, requires basic safety measures and has a predictable outcome.
The doctor has ordered Polycillin (ampicillin) Suspension 150 mg every 6 hours. The suggested dose for infants is 25-50 mg/kg/day in equally divided doses. The infant weighs 7 kg. The nurse should:
- A. Give the medication as ordered
- B. Give half the amount ordered
- C. Give the ordered amount every 12 hours
- D. Check the order with the doctor
Correct Answer: D
Rationale: The ordered dose (150 mg q6h = 600 mg/day) exceeds the safe range for a 7 kg infant (175-350 mg/day), requiring the nurse to verify the order with the doctor.
The nurse is caring for a client born at 42 weeks gestation. Which of the following potential clinical findings should the nurse anticipate for a postterm newborn? Select all that apply.
- A. Deep plantar creases
- B. Dry, cracked, peeling skin
- C. Lanugo on the extremities
- D. Long fingernails and scalp hair
- E. Minimal or absent vernix
Correct Answer: A,B,D,E
Rationale: Postterm newborns often have deep plantar creases, dry/peeling skin, long nails/hair, and minimal vernix due to prolonged gestation. Lanugo is more common in preterm infants.
A sputum collection is ordered for an adult. How should the nurse plan to collect the specimen?
- A. Have the client rinse her mouth with mouthwash before collecting the specimen
- B. Collect the specimen in the morning
- C. Have the client use the collection cup every time she coughs during the day
- D. Encourage the client to drink lots of fluids before collecting the specimen
Correct Answer: B
Rationale: Morning sputum collection yields the most concentrated sample for accurate testing, typically for infections like tuberculosis, without needing mouthwash, all-day collection, or excessive fluids.
The nurse is preparing to administer scheduled medications to assigned clients. Which of the following medications should the nurse hold for clarification prior to administering?
- A. magnesium sulfate for a client with a magnesium level of 1.0 mEq/L (0.41 mmol/L)
- B. calcium acetate for a client with a phosphate level of 8.5 mg/dL (2.75 mmol/L)
- C. clopidogrel for a client with a platelet count of 70,000/mm³ (70 × 10â¹/L)
- D. metformin for a client with a hemoglobin A1c level of 11%
Correct Answer: C
Rationale: Clopidogrel increases bleeding risk in a client with low platelets (70,000/mm³), requiring clarification. The other medications align with the clients' conditions.