Nokea
The nurse is caring for a client admitted with chest pain and atrial fibrillation. The nurse accidentally gives the client the wrong dose of digoxin. The client is monitored throughout the shift and no ill effects are noted. Which actions by the nurse are correct? Select all that apply.
- A. fill out an incident report and make a note of it in the nurse's notes
- B. print out rhythm strips every 2 hours and place on the client's chart
- C. fill out an incident report and notify the health care provider for further orders
- D. notify the health care provider at the end of the shift, since no ill effects were observed
- E. notify the pharmacy that they loaded the wrong dose in the automatic medication dispensing system
Correct Answer: C
Rationale: Filling out an incident report and notifying the provider immediately are necessary to address the medication error and ensure client safety, even if no ill effects were observed.
You may also like to solve these questions
The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
- A. Edema of the extremity and pain at the incision site
- B. A temperature of 99.6°F and redness of the incision
- C. Serous drainage noted at the surgical area
- D. A loss of posterior tibial and dorsalis pedis pulses
Correct Answer: D
Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.
The nurse is preparing to teach a client about phenytoin sodium (Dilantin). Which fact would be most important to teach the client regarding why the drug should not be stopped suddenly?
- A. Physical dependence can develop over time.
- B. Status epilepticus can develop.
- C. A hypoglycemic reaction can develop.
- D. Heart block can develop.
Correct Answer: B
Rationale: Abruptly stopping phenytoin can precipitate status epilepticus, a life-threatening condition, due to loss of seizure control.
The charge nurse is making an assignment for an LPN on an upcoming shift. Which assignment would be appropriate?
- A. a client with a recent head injury and active seizures
- B. a post-operative patient requiring vital sign monitoring every hour
- C. a post-operative patient receiving a blood transfusion
- D. a client with diabetes requiring discharge instruction on insulin injection
Correct Answer: B
Rationale: Vital sign monitoring is within the LPN’s scope. Seizure management, blood transfusions, and discharge teaching require RN expertise.
The nurse is seeing a client and her 11-month-old baby in the clinic for a wellness checkup. Which comment by the mother would prompt the nurse to notify the health care provider?
- A. She loves to play peekaboo.
- B. She loves to look at herself in the mirror.
- C. She does not like to be around strangers.
- D. She does not try to crawl when I put her down.
Correct Answer: D
Rationale: Lack of crawling at 11 months may indicate developmental delay, requiring provider evaluation. Other behaviors are age-appropriate.
A client is hospitalized with an acute myocardial infarction. Which nursing diagnosis reflects an understanding of the cause of acute myocardial infarction?
- A. Decreased cardiac output related to damage to the myocardium
- B. Impaired tissue perfusion related to an occlusion in the coronary vessels
- C. Acute pain related to cardiac ischemia
- D. Ineffective breathing patterns related to decreased oxygen to the tissues
Correct Answer: B
Rationale: Impaired tissue perfusion due to coronary occlusion is the primary cause of acute myocardial infarction.