Nokea
What times should the nurse measure vital signs? Select all that apply.
- A. 1500
- B. 1600
- C. 1800
- D. 1000
- E. 1200
Correct Answer: A,B,C,G,H
Rationale: Times align with fever monitoring.
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The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?
- A. Expel the air in the prefilled syringe prior to injection.
- B. Rotate injections between the abdomen and gluteal areas.
- C. Massage the injection site to increase absorption.
- D. Inject in the abdominal area at least 2 inches from the umbilicus.
Correct Answer: D
Rationale: Abdominal site ensures absorption.
After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?
- A. Request removal initiated by the Health Information Manager.
- B. Make an electronic addendum following the 1400 documentation.
- C. Create an electronic correction after 1400 notes are officially unlocked.
- D. Enter the occurrence after the 1400 notes and identify as 'late entry.'
Correct Answer: D
Rationale: Late entries maintain accuracy.
The primary nurse went on break at 1845. The covering nurse gave a second dose of insulin because of being unaware the primary nurse gave the ordered dose. Which error prevention techniques would have helped to avoid this?
- A. Double check all dosage calculations.
- B. nusually large or small doses.
- C. Compare the medication label to the order.
- D. Use at least 2 client identifiers before administering a dose.
- E. Involve and educate clients in medication administration.
- F. Document all medication in the electronic record as soon as it is given.
Correct Answer: A,C,D,E.F
Rationale: Documentation and verification prevent errors.
The client had a large, loose stool.
Vital signs: Temperature 98.7°F (37°C) orally. Heart rate 73 beats/minute.
Blood pressure 144/82 mm Hg. The client had a large, loose stool. The client had a large, loose stool.
Place the client on contact precautions.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take, and two parameters to assess the client’s progress.
- A. Collect stool for culture, Start a high-fiber diet., Administer an oral steroid.,Make the client NPO
- B. Secretory diarrhea.Steatorrhea,Motility diarrhea,Osmotic diarrhea
- C. Heart rate, Serum potassium,Respiratory rate, Urine sodium
Correct Answer:
Rationale: Secretory diarrhea fits; stool culture and NPO address infection; heart rate and potassium monitor dehydration.
The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?
- A. Administering the medication to a client behind a closed curtain.
- B. Informing a client that the medication being administered is a vitamin.
- C. Placing a client in restraints without having a healthcare provider’s order.
- D. Enlisting security personnel to assist with restraining the client.
Correct Answer: B
Rationale: Deception violates informed consent.