Nokea
The nurse has documented a treatment on the wrong client's record. Which of the following methods of indicating the error is correct?
- A. The nurse draws a straight line through the incorrect entry and writes 'error' above it and initials the correction.
- B. The nurse uses correction fluid to cover the incorrect entry.
- C. The nurse draws multiple lines through the incorrect entry so it is unreadable, writes 'error' above it, and initials the correction.
- D. The nurse leaves the incorrect entry in place, writes 'error' in the margin, and initials and dates the notation.
Correct Answer: A
Rationale: A single line through the error with 'error' written above and initialed (A) maintains transparency while correcting the record. Correction fluid (B) is unacceptable, multiple lines (C) obscure the record, and margin notes (D) are insufficient.
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A 10-year-old girl has been diagnosed with scabies. There are three other children and two adults living in the household. The nurse can best educate caregivers by stating,
- A. Scabies is only transmitted through person-to-person contact.'
- B. Everyone in the household needs to receive treatment.'
- C. If anyone shows symptoms, come into the clinic for treatment.'
- D. Since the child has started treatment, she is no longer contagious.'
Correct Answer: B
Rationale: Scabies is highly contagious via skin-to-skin contact or shared items. All household members should be treated simultaneously to prevent reinfestation, regardless of symptoms.
The nurse is caring for a client with a small-bowel obstruction. A Salem sump nasogastric tube (NGT) is in place. Which finding by the nurse requires corrective action? Select all that apply.
- A. There is a sudden decrease in output.
- B. The NGT is set to low continuous suction.
- C. The NGT is set to medium intermittent suction.
- D. The patient is positioned in the semi-Fowler's position.
- E. The client dislodges the tube and the nurse replaces it, confirming placement by X-ray before use.
Correct Answer: A, C
Rationale: A sudden decrease in output may indicate blockage or displacement, requiring assessment. Medium intermittent suction is inappropriate for a Salem sump, which requires low continuous suction. Other actions are correct.
The nurse is preparing to administer a dose of regular insulin to a client based on a sliding scale. The client’s blood glucose is 320 mg/dL. The sliding scale orders 6 units of regular insulin for a blood glucose of 301–350 mg/dL. Which of the following actions should the nurse take?
- A. Administer 6 units of regular insulin.
- B. Administer 8 units of regular insulin.
- C. Withhold the insulin and notify the physician.
- D. Recheck the blood glucose in 30 minutes.
Correct Answer: A
Rationale: the sliding scale indicates 6 units for a blood glucose of 320 mg/dL, so the dose is correct
The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
- A. I should have a bottle of Ipecac for each of my children.
- B. I should induce vomiting if my child swallows lighter fluid.
- C. Giving my child water or milk may help dilute the poison.
- D. Proper storage is the key to poison prevention in the home.
Correct Answer: B
Rationale: vomiting contraindicated when child ingests hydrocarbons due to danger of aspiration
A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:
- A. Hypothyroidism
- B. Diabetic ulcers
- C. Ulcerative colitis
- D. Pneumonia
Correct Answer: A
Rationale: Hypothyroidism poses the least risk of infection or complications, making it the safest roommate choice for a surgical client.