Nokea
The nurse-manager on the medical unit is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.
- A. Admission to the hospital.
- B. Transfer to the nursing home.
- C. Transfer of a client from surgery to the surgical unit.
- D. Admission to a home health agency from the hospital.
- E. Move from a double room to a single room on the same unit.
Correct Answer: A,B,C,D
Rationale: Medication reconciliation is required during transitions of care (admission, transfers, discharge to home health) to ensure accuracy. Moving rooms on the same unit does not typically require reconciliation.
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What is the primary goal of multidisciplinary case conferences?
- A. To fulfill the nurse's role in terms of collaboration
- B. To plan and provide for optimal client outcomes
- C. To solve complex multidisciplinary patient care problems
- D. To provide educational experiences for experienced nurses
Correct Answer: B
Rationale: The primary goal of multidisciplinary case conferences is to plan and provide for optimal client outcomes by bringing together various professionals to coordinate care and address the client's needs holistically.
The nurse is caring for a client with a suspected tension pneumothorax. Which finding requires immediate action?
- A. Tracheal deviation
- B. Mild dyspnea
- C. Oxygen saturation of 92%
- D. Subcutaneous emphysema
Correct Answer: A
Rationale: Tracheal deviation is a life-threatening sign of tension pneumothorax, indicating mediastinal shift and requiring immediate decompression.
Which nursing assessment findings indicate normal vital signs in a newborn infant?
- A. Pulse, 112; respiratory rate, 24
- B. Pulse, 124; respiratory rate, 28
- C. Pulse, 144; respiratory rate, 48
- D. Pulse, 164; respiratory rate, 55
Correct Answer: C
Rationale: The normal pulse rate for a newborn is 120 to 160. The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute. Therefore, the other options are incorrect.
A client with a diagnosis of rheumatoid arthritis is prescribed adalimumab (Humira). The nurse should monitor the client for which of the following side effects?
- A. Infection.
- B. Hypotension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Adalimumab, a TNF inhibitor, increases the risk of infections due to immune suppression.
The primary health care provider prescribes 650 mg of an antibiotic to be administered intravenously every 6 hours. The medication label reads as follows: reconstitute with 4.8 mL of bacteriostatic water to yield 2 g in 5 mL. How many mL should the nurse withdraw from the vial for 1 dose? Fill in the blank. Record the answer using 1 decimal place.
Correct Answer: 1.6 mL
Rationale: Convert 2 g to mg and then use the formula for calculating medication doses. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal 3 places to the right. Therefore, 2 g = 2000 mg. Formula: Desired / Available x Available Volume = 650 mg / 2000 mg x 5 mL = 1.625 mL = 1.6 mL.