Nokea
Which actions by a nurse are reportable to the state board of nursing? Select all that apply.
- A. Administering hydromorphone without a prescription
- B. Being habitually tardy to work
- C. Documenting an intervention that was not performed
- D. Stealing narcotics
- E. Walking off duty in the middle of a shift
Correct Answer: A,C,D
Rationale: Administering medication without a prescription, falsifying documentation, and stealing narcotics are reportable to the state board. Tardiness and leaving a shift are not typically reportable.
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The nurse notes that a client with COPD demonstrates increased dyspnea in certain positions. Which position is most likely to lessen the client's dyspnea?
- A. Lying supine with a single pillow
- B. Standing or sitting upright
- C. Side lying with the head elevated
- D. Lying with head slightly lowered
Correct Answer: B
Rationale: The client with chronic obstructive pulmonary disease has increased difficulty breathing when lying down. His respiratory effort is improved by standing or sitting upright or by having the bed in high Fowler's position. Answers A, C, and D do not alleviate the client's dyspnea; therefore they are incorrect.
The nurse is reinforcing teaching about circumcision care with the parent of a newly circumcised newborn. Which statement by the parent would require follow-up?
- A. I should change my baby's diaper at least every 4 hours.
- B. I should notify the health care provider if there is odorous discharge from the site.
- C. I will apply light pressure with gauze if there is bleeding at the site.
- D. I will clean the site with alcohol-based wipes or soap and water.
Correct Answer: D
Rationale: Alcohol-based wipes are too harsh for a circumcision site; gentle soap and water are recommended, requiring follow-up. Other statements are correct.
An RN from the women's health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse?
- A. A newly diagnosed client with type 2 diabetes mellitus who is learning foot care
- B. A client from a motor vehicle accident with an external fixation device on the leg.
- C. A client admitted for a barium swallow after a transient ischemic attack
- D. A newly admitted client with a diagnosis of pancreatic cancer
Correct Answer: B
Rationale: This client is the most stable, requires basic safety measures and has a predictable outcome.
The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first?
- A. Alert the supervising registered nurse
- B. Check the client's blood pressure and pulse
- C. Listen to the fetal heart rate
- D. Turn the client to a lateral position
Correct Answer: D
Rationale: Symptoms suggest supine hypotensive syndrome; turning the client to a lateral position relieves uterine pressure on the vena cava, improving blood flow.
The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of
- A. Anonymity
- B. Beneficence
- C. Justice
- D. Autonomy
Correct Answer: D
Rationale: Autonomy. Individuals must be free to make independent decisions about participation in research without coercion from others.