Nokea
The nurse has attended a staff education program about incident reporting. It would indicate effective understanding if the nurse states that the primary purpose of incident reporting is to
- A. implement corrective measures needed to prevent recurrence.
- B. collect data about errors and compare it to different time periods.
- C. communicate the error(s) to other departments within the facility.
- D. notify the individual involved of the deviation from the standard of care.
Correct Answer: A
Rationale: The primary purpose of incident reporting (A) is to implement corrective measures to prevent recurrence, enhancing client safety. Data collection (B), interdepartmental communication (C), and individual notification (D) are secondary benefits of the reporting process.
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The nurse has become aware of the following client situations. The nurse should first follow up with which client? A client
- A. with a chest tube that has tidaling in the water seal chamber.
- B. that is receiving mechanical ventilation and is occasionally biting on the tube.
- C. that is receiving albuterol via a nebulizer and reports headache and nervousness.
- D. with pneumonia that has become restless and confused.
Correct Answer: D
Rationale: Restlessness and confusion in pneumonia (D) suggest hypoxia or worsening infection, requiring immediate follow-up to prevent deterioration. Chest tube tidaling (A) is normal, tube biting (B) is concerning but less acute, and albuterol side effects (C) are expected.
The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate?
- A. Prepare for intubation.
- B. Prepare to administer a dopamine infusion.
- C. Administer naloxone.
- D. Start an IV infusion of normal saline.
Correct Answer: C
Rationale: Respiratory depression (RR 8) and hypotension post-morphine (C) indicate opioid overdose, requiring naloxone to reverse effects, per ACLS guidelines. Intubation (A), dopamine (B), and saline (D) are secondary or inappropriate without reversal.
The nurse is caring for a client who is postoperative following a lobectomy. The client is receiving fentanyl via an epidural. The nurse should monitor the client for which complication?
- A. Diarrhea
- B. Hypotension
- C. Hyperventilation
- D. Urinary incontinence
Correct Answer: B
Rationale: Epidural fentanyl can cause hypotension (B) due to vasodilation, a serious complication requiring monitoring. Diarrhea (A), hyperventilation (C), and urinary incontinence (D) are less common or unrelated.
The nurse has care of the following client situations under their care. The nurse should first assess which client?
- A. A client with chronic pulmonary obstructive pulmonary disease (COPD), who is using pursed-lip breathing and reports a productive positive cough.
- B. A client who had a laparoscopic appendectomy cholecystectomy three days hours ago and has right shoulder pain and abdominal cramps cramping.
- C. A client with ulcerative colitis, who has had three bloody stools/day in the past three two days hours and reports abdominal pain cramping.
- D. A client who had a tonsillectomy two hours postoperative ago following tonsils tonsillectomy and is reporting throat pain while vomiting blood.
Correct Answer: D,C
Rationale: Vomiting blood post-tonsillectomy (C) suggests hemorrhage, a life-threatening surgical emergency requiring immediate assessment. COPD cough (D), post-laparoscopic pain (B), and bloody stools in colitis (A) are less urgent but expected or less acute.
The nurse has received the following prescriptions for newly admitted clients. The nurse should first administer which of the following?
- A. Enoxaparin to a client with a platelet count of 165,000 mm3 (165 × 10^9/L) [150-400 mm3, 130-380 × 10^9/L]
- B. Warfarin to a client with an international normalized ratio of 2.4 [0.9-1.2 seconds]
- C. Packed red blood cells to a client with a hemoglobin of 6.1 g/dL (3.78 mmol/L) [Female: 12-16 g/dL, Male: 14-18 g/dL, Female 115-155 g/L, Male 125-170 g/L]
- D. Regular insulin to a client with a blood glucose of 285 mg/dL (15.77 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
Correct Answer: C
Rationale: Packed red blood cells for hemoglobin of 6.1 g/dL (C) is the priority to address severe anemia, which can cause tissue hypoxia. Enoxaparin (A) is safe with normal platelets, warfarin (B) is therapeutic at INR 2.4, and insulin (D) is urgent but less critical than severe anemia.