Nokea
Which incidence should be documented on an unusual incident report?
- A. The client leaves the hospital against the doctor's advice.
- B. The client develops a fever after receiving a blood transfusion.
- C. The client reports an upset stomach after taking an antibiotic.
- D. The client falls in her bathroom.
Correct Answer: D
Rationale: A fall is an unusual incident requiring documentation due to potential injury and liability. Leaving AMA, transfusion fever, or upset stomach are notable but less likely to require an incident report.
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A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need?
- A. Close monitoring for hypotension
- B. Gradually increasing the prednisone dose
- C. Increasing the insulin dose
- D. Monitoring and recording intake and output
Correct Answer: C
Rationale: Prednisone increases blood glucose, necessitating a higher insulin dose in diabetes. Hypotension is not a primary concern, prednisone is not typically titrated upward, and intake/output monitoring is less critical.
The women’s health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse?
- A. Client reports heavy menstrual cycles
- B. History of breast cancer in maternal aunt
- C. History of deep venous thrombosis
- D. Weight is 186 lb (84.4 kg) and BMI is 31.0 kg/m^2
Correct Answer: C
Rationale: Deep venous thrombosis is a contraindication for estrogen-containing contraceptives like the patch due to increased clotting risk. Heavy menses, family history of breast cancer, and obesity are less critical.
The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
- A. Skin irritation
- B. Drug tolerance
- C. Severe headaches
- D. Postural hypotension
Correct Answer: B
Rationale: Drug tolerance. Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.
Which symptom is considered an adverse reaction to Kantrex (kanamycin)?
- A. Diminished hearing
- B. Hypotension
- C. Hepatomegaly
- D. Petechiae
Correct Answer: A
Rationale: Kanamycin, an aminoglycoside, is ototoxic, and diminished hearing is a known adverse reaction requiring monitoring.
The nurse is talking with a client with unilateral facial paralysis. Which of the following statements by the client would require follow-up? Select all that apply.
- A. I may chew food on either side of my mouth because it does not hurt
- B. I need to use my fingers to close my eyelid after instilling eye drops
- C. I should prepare meals that include soft, high-calorie foods
- D. I will place tape on my affected eyelid before I go to sleep
- E. I will put ice on the affected side of my face when it hurts
Correct Answer: A,E
Rationale: Chewing on the affected side risks injury due to impaired sensation, and ice may worsen symptoms in conditions like Bell’s palsy. Closing the eyelid, taping at night, and soft foods are appropriate for facial paralysis management.