Nokea
The nurse is planning a staff development conference about measures to reduce medication errors. It would be appropriate for the nurse to state which actions may help reduce medication errors? Select all that apply.
- A. Timely medication reconciliation
- B. Delay documentation of medication administration to the end of the shift
- C. Delegate medication transcription to unlicensed assistive personnel (UAP)
- D. Limit the use of verbal orders to emergent situations
- E. Place medication dispensing systems in high-traffic areas
Correct Answer: A,D
Rationale: Timely reconciliation and limiting verbal orders reduce errors; delayed documentation, UAP transcription, and high-traffic dispensing systems increase error risk.
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When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?
- A. Aching pain in the left calf
- B. Burning pain in the left calf
- C. Numbness and tingling in the left leg
- D. Coldness of the left foot and ankle
Correct Answer: D
Rationale: Complete arterial obstruction causes severe ischemia, leading to coldness of the affected limb (foot and ankle) due to absent blood flow. Aching or burning pain and numbness/tingling suggest partial occlusion or neuropathy, not complete obstruction.
What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?
- A. Tay-Sachs cells.
- B. Reed-Sternberg cells.
- C. Duchenne's cells.
- D. None of the above
Correct Answer: B
Rationale: Hodgkin's disease is diagnosed by the presence of Reed-Sternberg cells, large multinucleated cells, in the lymph node biopsy. Tay-Sachs and Duchenne's cells are unrelated to Hodgkin's.
The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next?
- A. Bladder distention.
- B. Headache.
- C. Postoperative pain.
- D. Ability to move the legs.
Correct Answer: A
Rationale: Epidural anesthesia can cause urinary retention due to sensory and motor nerve blockade. Assessing for bladder distention is critical to prevent complications like bladder overdistension.
A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first?
- A. Tell the client it is impossible to feel the pain.
- B. Show the client that the toes are not there.
- C. Explain to the client that her pain is real.
- D. Give the client the prescribed opioid analgesic.
Correct Answer: C
Rationale: Phantom limb pain is real and distressing; acknowledging it validates the client's experience.