Nokea
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. The nurse performs range-of-motion (ROM) exercises for a client with second- and third-degree burns of the chest.
- B. The nurse sits with a client who suffers from depression while he eats his lunch.
- C. The nurse caring for a client with myasthenia gravis administers the 7 AM dose of neostigmine bromide (Prostigmin) PO at 7:45 AM.
- D. The nurse instructs a 15-year-old girl who is sexually active about different types of contraceptives without consulting her parents.
Correct Answer: C
Rationale: Strategy: 'Negligence' indicates an incorrect action. (1) minimizes muscle atrophy (2) promotes eating, offer more frequent feedings of favorite foods (3) correct-delay in medication may cause difficulty in swallowing, might have difficulty taking medication (4) minor can request birth control without the parent's consent
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The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?
- A. Daily needs and concerns
- B. The overview cardiac rehabilitation
- C. Medication and diet guideline
- D. Activity and rest guidelines
Correct Answer: A
Rationale: At 2 days post-MI, the client's education should be focused on the immediate needs and concerns for the day.
The client with a suspected pituitary tumor will most likely exhibit symptoms of:
- A. Alteration in visual acuity
- B. Frequent diarrhea
- C. Alterations in blood glucose
- D. Urticaria
Correct Answer: A
Rationale: Pituitary tumors can compress the optic chiasm, leading to visual disturbances. Diarrhea , blood glucose changes , and urticaria are less commonly associated with pituitary tumors.
The LPN/LVN has delegated basic hygienic care of several clients to a certified nursing assistant. Which action by the nurse will ensure that the clients receive the best care?
- A. Observe the nursing assistant during the performance of all care
- B. Ask the nursing assistant if there were any problems
- C. Check the nursing assistant's charting
- D. Observe the clients following administration of care by the nursing assistants
Correct Answer: D
Rationale: Observing clients post-care ensures care was performed correctly and identifies issues like skin integrity or comfort, ensuring quality. Constant observation, questioning, or charting checks are less direct.
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions is the PRIORITY?
- A. Encourage the client to log-roll when turning.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Encouraging log-rolling is the priority to prevent spinal strain and maintain alignment post-lumbar laminectomy. Options B, C, and D are important but secondary: pain management, drain monitoring, and incision checks follow proper positioning.
The client has recently had a colostomy. The nurse is providing home care and is teaching the client about care of his colostomy. Which comment by the client indicates understanding of the care of his colostomy?
- A. I will use hot water to irrigate the colostomy.'
- B. If my skin gets red, I will put alcohol on it.'
- C. I will irrigate the colostomy at the same time each day.'
- D. I should do the irrigation while lying in bed.'
Correct Answer: C
Rationale: Regularly timed colostomy irrigation promotes predictable bowel patterns, indicating understanding. Hot water, alcohol, or bed irrigation are incorrect.