Nokea
Which assessment should the nurse document when charting by exception?
- A. Active bowel sounds in the lower right quadrant.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Basilar lung sounds that are diminished in the left lung.
- D. Capillary refill of 2 seconds in the lower right foot.
Correct Answer: C
Rationale: Abnormal findings are documented.
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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.
The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?
- A. Record a palpable systolic pressure of 90 mm Hg.
- B. Release the manometer valve immediately.
- C. Document the absence of the radial pulse.
- D. Inflate the blood pressure cuff to 120 mm Hg.
Correct Answer: D
Rationale: Inflate above pulse disappearance for accuracy.
To assess the quality of the client’s abdominal pain, which approach should the nurse use?
- A. Provide a numeric pain scale.
- B. Ask the client to describe the pain.
- C. Observe body language and movement.
- D. Identify effective pain relief measures.
Correct Answer: B
Rationale: Descriptive assessment captures pain quality.
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.
A 64-year-old female client with a 3-day history of cough and chest pain is admitted for presumed pneumonia. The client has a history of type 2 diabetes mellitus and takes insulin glargine 17 units in the morning and 17 units in the evening. Which of the following actions should the nurse take to prevent medication errors?
- 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: Verification and documentation ensure safety.