Nokea
The nurse participates in a task force to reduce errors related to telephone and verbal orders. The nurse should recommend that
- A. unlicensed assistive personnel (UAP) can take a physician's telephone prescription.
- B. use more abbreviations when transcribing a physician's order.
- C. when repeating an order back to the physician, repeat the numbers individually.
- D. verbal and telephone orders are limited to emergency situations.
- E. transcribing telephone and verbal orders be delayed until a second nurse can review the order.
Correct Answer: C,D
Rationale: Repeating numbers individually and limiting verbal orders to emergencies reduce errors. UAP cannot take prescriptions, abbreviations increase errors, and delays risk patient safety.
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The nurse is caring for a client who has soft-limb wrist restraints applied. The highest priority for the nurse is to
- A. Provide the client with opportunities to discuss their feelings.
- B. Document the neurovascular assessments.
- C. Assess the client's mood and affect.
- D. Offer nutrition and hydration.
Correct Answer: B
Rationale: Neurovascular assessments ensure circulation and safety, the highest priority with restraints. Other actions are important but secondary.
The nurse is caring for several clients in a long-term care facility. Which interventions should the nurse implement to reduce the risk of injury from falls? Select all that apply.
- A. Avoid administering ibuprofen at night
- B. Secure the call button to the side of the bed
- C. Keep the bed in the lowest position
- D. Place fall risk bands on clients at risk of falling
- E. Reposition clients off of bony prominences every two hours
Correct Answer: B,C,D
Rationale: Securing the call button, keeping the bed low, and using fall risk bands reduce fall risk. Ibuprofen and repositioning are unrelated to fall prevention.
The nurse has attended a conference on intraoperative nursing interventions for the older adult. which of the following statements by the nurse would indicate the need for additional teaching?
- A. Warming devices should be used to prevent the client from developing hypothermia
- B. The client's head and feet should be covered during surgery
- C. Clients should be slid, not lifted into the proper position
- D. Providing extra padding for clients with decreased peripheral circulation is important
Correct Answer: C
Rationale: Sliding clients instead of lifting can cause shear injuries, particularly in older adults with fragile skin. Warming devices, covering extremities, and extra padding are appropriate to prevent hypothermia and protect pressure points, indicating correct understanding.
The nurse is reviewing the labs of a child who has recently had oral surgery. Which of the following lab results should the nurse pay the closest attention to?
- A. BUN level
- B. Prothrombin time
- C. Creatinine level
- D. Viral load
Correct Answer: B
Rationale: Prothrombin time assesses clotting, critical post-oral surgery to monitor bleeding risk. BUN and creatinine assess kidney function, and viral load is irrelevant.
The nurse is preparing a client scheduled for hip arthroplasty in two hours. The nurse has received a prescription for tranexamic acid. The nurse understands that this medication has had a therapeutic effect when the client has
- A. decreased postoperative pain
- B. increased postoperative vital capacity
- C. less postoperative blood loss
- D. no surgical site infection
Correct Answer: C
Rationale: Tranexamic acid is an antifibrinolytic that reduces bleeding by inhibiting clot breakdown. Its therapeutic effect is evident with less postoperative blood loss. It does not directly affect pain, vital capacity, or infection rates.