Nokea
Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Administered 9.00 AM medication at 9.30 AM
- B. Developed worsening cellulitis after missing antibiotics for 1 day
- C. Has a seizure and a history of epilepsy
- D. Slides off the edge of the bed and ends up sitting on the floor
- E. Waits 4 hours to be transported for STAT diagnostic CT scan
Correct Answer: B,D,E
Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.
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The nurse is observing a staff member caring for a client who has varicella with active lesions. The nurse should intervene if the staff member is observed
- A. removing the protective gown with the contaminated side facing away from the body
- B. placing a surgical mask on the client before transport outside of the client's room
- C. removing the N95 respirator mask while inside the client's room
- D. keeping the door to the client's room closed at all times
Correct Answer: C
Rationale: Removing an N95 mask inside the room of a varicella client risks airborne exposure, requiring intervention. Other actions (A, B, D) follow correct infection control protocols.
A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply.
- A. I don't plan on eating any more frozen meals.'
- B. I plan to take my diuretic pill in the morning.'
- C. I will weigh myself at least every other day.'
- D. I'm going to look into joining a cardiac rehabilitation program.'
- E. Ibuprofen works best for me when I have pain.'
Correct Answer: E
Rationale: Ibuprofen can cause fluid retention, worsening heart failure, and requires further teaching. Avoiding frozen meals , morning diuretic , regular weighing , and cardiac rehab are appropriate.
The practical nurse is assisting the registered nurse in creating a teaching plan for the parents of a child diagnosed with pediculosis capitis. Which instructions should be included in the teaching plan? Select all that apply.
- A. It is not necessary to treat other children in the household
- B. Soak the child's comb and hair accessories in boiling water for 10 minutes
- C. The family pet will need treatment with a pediculicide
- D. Use a nit comb daily for 2 weeks after pediculicide treatment
- E. Vacuum the furniture, carpets, and mattresses every few days
Correct Answer: B,D,E
Rationale: For pediculosis capitis (head lice), soaking combs in boiling water , using a nit comb daily , and vacuuming furniture prevent reinfestation. Other children should be checked and treated if infested (A is incorrect), and pets do not require treatment as lice are human-specific.
The nurse aus.Concurrent with the above question, the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?
- A. Administer an inhaled bronchodilator
- B. Check marked insertion depth of the tube
- C. Request a prescription for a diuretic
- D. Start the client on incentive spirometry
Correct Answer: C
Rationale: Crackles and diminished breath sounds in the lung bases postpartum suggest fluid overload or pulmonary edema, possibly due to prolonged labor or excessive IV fluids. Requesting a diuretic is appropriate to reduce fluid overload. Bronchodilators are for bronchospasm, checking tube depth is irrelevant without an endotracheal tube, and incentive spirometry is less urgent.
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.
- A. Perform fundal massage
- B. Document the exact time of events
- C. Flex the client's legs back against the abdomen
- D. Request immediate assistance from other nurses
- E. Apply downward pressure above the client's symphysis pubis
Correct Answer: B,C,D,E
Rationale: For shoulder dystocia: document timing for accuracy, flex legs for McRoberts maneuver, request help for additional support, and apply suprapubic pressure to dislodge the shoulder. Fundal massage is for postpartum hemorrhage.