Nokea
Which action by the primary nurse would require the unit manager to intervene?
- A. The nurse uses a correction fluid to correct a charting mistake.
- B. The nurse is shredding the worksheet at the end of the shift.
- C. The nurse circles an omitted medication time on the MAR.
- D. The nurse documents narcotic wastage with another nurse.
Correct Answer: A
Rationale: Using correction fluid obscures records, violating charting standards, requiring intervention. Shredding worksheets, circling omissions, or documenting wastage is appropriate.
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The client is being discharged from the hospital for intractable pain secondary to cancer and is prescribed morphine, a narcotic. Which statement indicates the client understands the discharge instructions?
- A. I will be sure to have my prescriptions filled before any holiday.
- B. There should not be a problem having the prescriptions filled anytime.
- C. If I run out of medications, I can call the HCP to phone in a prescription.
- D. There are no side effects to morphine I should be concerned about.
Correct Answer: A
Rationale: Filling prescriptions before holidays ensures access to narcotics, reflecting understanding of controlled substance challenges. Other statements are inaccurate or unsafe.
The client who is of the Jewish faith died during the night. The nurse notified the family, who do not want to come to the hospital. Which intervention should the nurse implement to address the family's behavior?
- A. Take no further action because this is an accepted cultural practice.
- B. Notify the hospital supervisor and report the situation immediately.
- C. Call the local synagogue and request the rabbi go to the family's home.
- D. Assume the family does not care about the client and follow hospital protocol.
Correct Answer: A
Rationale: In Jewish tradition, some families avoid hospital visits post-death, delegating care to professionals, a cultural norm. Supervisor reports, rabbi involvement, or assumptions are inappropriate.
The nurse is orienting to a hospice organization. Which statement does not indicate a right of the terminal client? The right to:
- A. Be treated with respect and dignity.
- B. Have particulars of the death withheld.
- C. Receive optimal and effective pain management.
- D. Receive holistic and compassionate care.
Correct Answer: B
Rationale: Terminal clients have rights to dignity, pain management, and holistic care, per hospice principles. Withholding death particulars is not a recognized right and may violate transparency.
Which act protects the nurse against a malpractice claim when the nurse stops at a motor-vehicle accident and renders emergency care?
- A. The Health Insurance Portability and Accountability Act.
- B. The State Nurse Practice Act.
- C. The Emergency Rendering Aid Act.
- D. The Good Samaritan Act.
Correct Answer: D
Rationale: The Good Samaritan Act protects nurses providing emergency care voluntarily, limiting malpractice liability. HIPAA, Nurse Practice Act, or fictional acts don’t apply.
The client received a liver transplant and is preparing for discharge. Which discharge instruction should the nurse teach?
- A. The immune-suppressant drugs must be tapered off when discontinuing them.
- B. There may be slight foul-smelling drainage on the dressing for a few days.
- C. Notify the HCP immediately if a cough or fever develops.
- D. The skin will turn yellow from the antirejection drugs.
Correct Answer: C
Rationale: Cough or fever may indicate infection, critical post-transplant due to immunosuppression. Tapering drugs, foul drainage, or jaundice are incorrect or misleading.