Nokea
The nurse is assessing a client with suspected hyperthyroidism. Which of the following findings would the nurse expect?
- A. Weight gain and lethargy.
- B. Tremors and heat intolerance.
- C. Bradycardia and cool skin.
- D. Increased appetite and constipation.
Correct Answer: B
Rationale: tremors and heat intolerance are common symptoms of hyperthyroidism due to increased metabolic rate
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The nurse is preparing to administer a dose of morphine sulfate to a client with postoperative pain. The client’s respiratory rate is 10 breaths per minute. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer half the dose and monitor the client.
- D. Recheck the respiratory rate in 30 minutes.
Correct Answer: B
Rationale: a respiratory rate of 10 breaths per minute is low, and morphine can further depress respiration, so the dose should be withheld
The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:
- A. Fraud
- B. Malpractice
- C. Negligence
- D. Tort
Correct Answer: A
Rationale: Falsifying medical records, such as charting unadministered medications, constitutes fraud.
The nurse is assisting a client who has experienced a left-sided cerebral vascular accident. The client requires assistance with personal hygiene. Which intervention should the nurse do initially?
- A. provide positive feedback
- B. place hygiene items on the client's left side
- C. provide assistive devices
- D. assess abilities and level of deficit
Correct Answer: D
Rationale: Assessing the client’s abilities and deficits first guides appropriate hygiene assistance, considering left-sided neglect or weakness.
The nurse is at the nurses' station charting when a physician comes up and says, 'Since you are already logged into the computer, I need you to look up some labs on a client.' The client is not cared for by this nurse. Which response by the nurse is most appropriate?
- A. Let me check that for you in a moment.
- B. Why don't you call the lab? That will be quicker.
- C. That is not my client, but I will get his nurse for you.
- D. I can't do that because of HIPAA, but I will let the charge nurse look it up.
Correct Answer: D
Rationale: Accessing a client's lab results without authorization violates HIPAA, as the nurse is not assigned to the client. The charge nurse can ensure proper access.
The nursing assistant finds a client on the floor. Once the client is safe, which of the following should the nurse do next?
- A. document the event in the client's medical record only
- B. document the event in the client's medical record and file an incident report
- C. document the event in the client's medical record and have the nursing assistant file an incident report
- D. have the nursing assistant file an incident report
Correct Answer: B
Rationale: Falls require documentation in the medical record and an incident report to track safety issues and ensure follow-up.