Nokea
The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
- A. That cannot be assessed
- B. That is in situ
- C. With increasing lymph node involvement
- D. With distant metastasis
Correct Answer: B
Rationale: Tis indicates a tumor in situ, meaning it is noninvasive and confined to its original site, requiring specific care planning.
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After the physician performs an amniotomy, the nurse's first action should be to assess the:
- A. Degree of cervical dilation
- B. Fetal heart tones
- C. Client's vital signs
- D. Client's level of discomfort
Correct Answer: B
Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.
The nurse administers a dose of acetaminophen to the wrong client. Which of the following actions is the most appropriate after notifying the physician?
- A. Notify her supervisor and complete an incident report.
- B. Ask the physician for an order of acetaminophen to cover the inadvertent administration.
- C. Take no further action because acetaminophen is relatively benign.
- D. Document in the client's record that an error in drug administration occurred.
Correct Answer: A
Rationale: Medication errors require notifying the supervisor and completing an incident report (A) to ensure proper follow-up and system improvements. Retroactively obtaining an order (B) is unethical, assuming acetaminophen is benign (C) is unsafe, and documenting the error in the client's record (D) is inappropriate.
The physician has ordered Pentam (pentamidine) IV for a client with pneumocystis carinii. While receiving the medication, the nurse should carefully monitor the client's:
- A. Blood pressure
- B. Temperature
- C. Heart rate
- D. Respirations
Correct Answer: A
Rationale: Pentamidine can cause hypotension, so blood pressure monitoring is critical during administration.
An operating room nurse just received a client scheduled for a laparoscopic cholecystectomy, but discovers the consent form has not been signed. What is the most appropriate action?
- A. bring the client a new consent form and have him sign it right away
- B. call the surgeon and ask how she would like to proceed
- C. inform the nursing manager there is no signed consent form
- D. ask the unit manager if the surgery can be rescheduled for later in the day
Correct Answer: B
Rationale: Missing consent requires notifying the surgeon to ensure the client is informed and consents before proceeding, adhering to legal and ethical standards.
The client's intravenous (IV) line has a gauze pad wrapped around the IV catheter at the insertion site and a transparent dressing over the gauze dressing. How long after application should the nurse change the dressing?
- A. At the normal rotation time for the IV.
- B. When the transparent dressing loosens.
- C. In 48 hours.
- D. In 24 hours.
Correct Answer: B
Rationale: Transparent dressings should be changed when they loosen (B) or per facility policy (typically every 5-7 days unless soiled or loose). Fixed intervals (C, D) or IV rotation (A) do not apply directly.