Nokea
The nurse manager is developing a 'read-back' procedure to reduce medication administration errors. Which of the following are purposes of the 'read-back' requirement? Select all that apply.
- A. To prohibit orders and test results from being communicated verbally or by telephone.
- B. To ensure that orders and test results that are communicated verbally or by telephone are clear to the receiver of the information.
- C. To make sure that orders and test results that are communicated verbally or by telephone are confirmed by the individual giving the information.
- D. To minimize the risk of non-authorized personnel from giving orders which are communicated verbally or by telephone.
- E. To encourage the use of electronic medical records.
Correct Answer: B,C,D
Rationale: Read-back ensures clarity, confirmation, and authorized communication of verbal orders, reducing errors. It does not prohibit verbal orders or mandate electronic records.
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A client has nephrotic syndrome. To aid in the resolution of the client's edema, the physician orders 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome?
- A. Crackles in the lung bases.
- B. Blood pressure elevation.
- C. Cerebral edema.
- D. Cool skin temperature in lower extremities.
Correct Answer: B
Rationale: Albumin increases oncotic pressure, pulling fluid into the vascular space, which may elevate blood pressure. Crackles, cerebral edema, or cool extremities would indicate complications.
A client with cirrhosis reports itching. Which intervention should the nurse implement?
- A. Apply a heating pad.
- B. Administer an antihistamine.
- C. Encourage a hot shower.
- D. Apply a moisturizing lotion.
Correct Answer: D
Rationale: Moisturizing lotion relieves itching in cirrhosis by hydrating dry skin without exacerbating symptoms.
The nurse is assessing a client with a history of heart failure who is receiving a 500-mL I.V. bolus of 0.9% normal saline. To evaluate the client's response to the treatment, the nurse should especially monitor the client for which of the following?
- A. Hypotension.
- B. Increased urine output.
- C. Crackles in the lungs.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: In heart failure, fluid boluses can lead to pulmonary edema, so monitoring for lung crackles is critical to detect fluid overload.
A female client is treated for trichomoniasis with metronidazole (Flagyl). The nurse instructs the client that:
- A. The medication should not alter the color of the urine.
- B. She should discontinue oral contraceptive use during this treatment.
- C. She should avoid alcohol during treatment and for 24 hours after completion of the drug.
- D. Her partner does not need treatment.
Correct Answer: C
Rationale: Metronidazole can cause a disulfiram-like reaction with alcohol, so avoiding alcohol during and 24 hours after treatment is critical.
An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. Which of the following should the nurse do next?
- A. Put the child on nothing-by-mouth (NPO) status.
- B. Call to report this event to the physician.
- C. Wait a few minutes, then refeed the child.
- D. Administer the prescribed antiemetic.
Correct Answer: B
Rationale: Vomiting in an infant with increased ICP may indicate worsening pressure, requiring immediate physician notification.