Nokea
Which of the following examples should the nurse include in the teaching as an example of malpractice?
- A. Documenting communication with a provider in the progress notes of the client's medical record
- B. Placing a yellow bracelet on a client who is at risk for falls
- C. Leaving a nasogastric tube clamped after administering oral medication
- D. Administering potassium via IV bolus
Correct Answer: C
Rationale: The correct answer is C because leaving a nasogastric tube clamped after administering oral medication is an example of malpractice. This action can lead to obstruction and potential harm to the client. Documenting communication (A) is a standard practice to ensure accurate record-keeping. Placing a yellow bracelet (B) is a safety measure. Administering potassium via IV bolus (D) is within the scope of practice if done correctly.
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Which of the following findings indicates the newborn is experiencing withdrawal?
- A. Bulging fontanels
- B. Acrocyanosis
- C. Bradycardia
- D. Hypertonicity
Correct Answer: D
Rationale: The correct answer is D: Hypertonicity. This finding indicates the newborn is experiencing withdrawal because it is a common symptom of withdrawal from substances such as opioids or benzodiazepines. Hypertonicity refers to increased muscle tone, which can be observed through increased resistance to passive movement. It is a sign of central nervous system hyperirritability, often seen in newborns going through withdrawal. Bulging fontanels (A) are a sign of increased intracranial pressure. Acrocyanosis (B) is a normal finding in newborns and is due to immature circulation. Bradycardia (C) is a slow heart rate, which can be caused by various factors in newborns, not specifically indicative of withdrawal.
The client is at risk for developing-----due to---
- A. mania
- B. serotonin syndrome
- C. psychosis
- D. feelings of hopelessness
- E. adverse effects of paroxetine
- F. anxiety
Correct Answer: B,E
Rationale: Increasing paroxetine while discontinuing fluoxetine can lead to serotonin syndrome.
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
- A. Pale arid a 24 hr fluid deficit of 30 ml
- B. Sunken fontanels and dry mucous membranes
- C. Decreased appetite and irritability
- D. Temperature 38° C(100.4° Fl and pulse rate 124/min
Correct Answer: B
Rationale: The correct answer is B: Sunken fontanels and dry mucous membranes. These findings indicate severe dehydration in the infant, which is a critical condition that requires immediate intervention. Sunken fontanels suggest significant fluid loss, while dry mucous membranes are indicative of dehydration. Reporting these findings to the provider is crucial for prompt treatment to prevent further complications.
Incorrect Answer A: Pale and a 24 hr fluid deficit of 30 ml. Pale skin alone may not indicate severe dehydration, and a 24-hour fluid deficit of 30 ml is relatively small and not alarming.
Incorrect Answer C: Decreased appetite and irritability. These are common symptoms of gastroenteritis and may not necessarily indicate a need for immediate reporting to the provider.
Incorrect Answer D: Temperature 38° C and pulse rate 124/min. These vital signs are elevated but do not directly indicate severe dehydration requiring immediate reporting.
After notifying the provider, the nurse should-----and then-----
- A. prepare the client for cardiac catheterization
- B. request a prescription for an increase in statin medication
- C. administer oxygen at 2 L/min via nasal cannula
- D. request a prescription for a beta-blocker
- E. check a STAT cardiac troponin
- F. administer sublingual nitroglycerin
Correct Answer: C,F
Rationale: Oxygen and nitroglycerin are initial interventions for chest pain relief.
The client asks the nurse if the medication can be given 2 hr. earlier. Which of the following statements should the nurse make?
- A. I can start the medication 30 minutes earlier.
- B. I can adjust the time and schedule for when it's convenient for you.
- C. I can infuse the medication at a faster rate.â€
- D. I have up to 2 hours after the usual schedule time to give you this medication.â€
Correct Answer: D
Rationale: The correct answer is D because it adheres to safe medication administration practices. The nurse should explain to the client that there is a window of up to 2 hours after the usual schedule time to administer the medication safely. This ensures that the medication remains effective while also preventing any potential harm from giving it too early or too late.
Choice A is incorrect because starting the medication 30 minutes earlier may not fall within the safe administration window. Choice B is incorrect because adjusting the time solely based on convenience may compromise the medication's effectiveness. Choice C is incorrect because infusing the medication at a faster rate could lead to adverse effects.