Nokea
The nurse is caring for a hospitalized client. Which is the best example of narrative documentation to provide legal malpractice protection for the nurse after an adverse event?
- A. Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation.'
- B. Client reports IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor. Health care provider (HCP) notified.'
- C. IV site in right hand is red and swollen at 9:30 AM. IV line removed, bleeding controlled, and warm compress administered at 9:40 AM. Will monitor for swelling and pain every hour.'
- D. Package of green leaves found in client drawer at 1:00 PM. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings.'
Correct Answer: C
Rationale: Detailed, objective documentation (C) with times, actions, and follow-up plans provides the best legal protection. Options A, B, and D include assumptions, vague details, or irrelevant information.
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The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. Which of the following statements by the client would require follow-up?
- A. I will avoid taking over-the-counter aspirin.'
- B. I must avoid consuming green, leafy vegetables such as spinach and kale.'
- C. I should avoid consuming any caffeinated products.'
- D. I will talk with my health care provider before taking any nutritional supplements.'
Correct Answer: B
Rationale: Avoiding all green leafy vegetables (B) is incorrect; consistent intake is needed to maintain stable INR. Avoiding aspirin (A), caffeine (C), and consulting about supplements (D) are correct.
The nurse is reviewing laboratory test results for an 80-year-old client who has a methicillin-resistant Staphylococcus aureus infection and is receiving vancomycin. Which of the following test results would require immediate follow-up?
- A. elevated BUN
- B. decreased serum iron level
- C. decreased serum triglyceride level
- D. elevated capillary blood glucose level
Correct Answer: A
Rationale: Elevated BUN (A) may indicate nephrotoxicity, a serious side effect of vancomycin requiring immediate follow-up. Decreased iron (B) or triglycerides (C) are not directly related to vancomycin toxicity. Elevated glucose (D) may need monitoring but is less urgent.
Which of the following clients does the nurse identify as being at high risk for developing colorectal cancer? Select all that apply.
- A. Client who has a diet high in red meat and low in fiber
- B. Client who is morbidly obese
- C. Client with a 15-year history of ulcerative colitis
- D. Client with a 40-year history of cigarette smoking
- E. Client with a family history of colorectal cancer
Correct Answer: A, C, E
Rationale: High red meat/low fiber diet (A), ulcerative colitis (C), and family history (E) are established risk factors for colorectal cancer. Obesity (B) and smoking (D) have weaker associations.
The nurse is assisting the physician with an examination of a client with Addison's disease. During the examination, the nurse will note which change in the client's integumentary system?
- A. Edema of the hands and feet
- B. Hirsutism
- C. Bronze pigmentation
- D. Pendulous abdomen
Correct Answer: C
Rationale: Addison's disease causes bronze pigmentation due to increased ACTH. Edema , hirsutism , and pendulous abdomen are not typical.
The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?
- A. Contraction duration of 95 seconds
- B. Contraction frequency of every 3 minutes
- C. Contraction intensity of 45 mm Hg
- D. Uterine resting tone of 10 mm Hg
Correct Answer: A
Rationale: Contraction duration of 95 seconds (A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (B), intensity (C), and resting tone (D) are within normal limits.