Nokea
Which situation would be reportable to the state board of nursing?
- A. The facility fails to provide literature in both Spanish and English.
- B. The narcotic count has been incorrect on the unit for the past three days.
- C. The client fails to receive an itemized account of his bills and services received during his hospital stay.
- D. Needles and sharps are found in the client's waste can.
Correct Answer: B
Rationale: An incorrect narcotic count for three days suggests potential diversion or mismanagement of controlled substances a serious issue reportable to the state board of nursing. The other situations are administrative or safety issues but not typically reportable to the board.
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The nurse is preparing to administer an injection to a six-month-old when she notices a white dot in the infant's right pupil. The nurse should:
- A. Report the finding to the physician immediately.
- B. Record the finding and give the infant's injection.
- C. Recognize that the finding is a variation of normal.
- D. Check both eyes for the presence of the red reflex.
Correct Answer: A
Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or other serious conditions, requiring immediate reporting to the physician for evaluation.
An adolescent client with cystic acne has a prescription for Accutane (isotretinoin). Which lab work is needed before beginning the medication?
- A. Complete blood count
- B. Clean-catch urinalysis
- C. Liver profile
- D. Thyroid function test
Correct Answer: C
Rationale: Isotretinoin can cause liver toxicity, requiring a baseline liver profile to monitor for elevations in liver enzymes. CBC, urinalysis, and thyroid tests are not primary concerns.
The nurse is caring for a client with a history of asthma who is receiving Albuterol (Proventil). The nurse should monitor the client for:
- A. Tachycardia
- B. Hypotension
- C. Hypokalemia
- D. Hyperglycemia
Correct Answer: A
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to sympathetic stimulation. Hypotension, hypokalemia, and hyperglycemia are less frequent.
The client is admitted with a diagnosis of acute renal failure. Which laboratory value is most expected?
- A. Elevated creatinine
- B. Decreased potassium
- C. Elevated hemoglobin
- D. Decreased blood urea nitrogen
Correct Answer: A
Rationale: Elevated creatinine is a hallmark of acute renal failure, reflecting impaired kidney filtration. Hyperkalemia, decreased hemoglobin, and elevated BUN are more common than low potassium or BUN.
A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?
- A. Contractions every 2 minutes, lasting 100 seconds
- B. Fetal heart decelerations during a contraction
- C. Beat-to-beat variability between contractions
- D. Fetal heart decelerations at the beginning of contractions
Correct Answer: A
Rationale: These are tetanic in nature and can cause rupture of the uterus. The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. Beat-to-beat variability is a normal finding and demonstrates fetal well-being. The FHR may decrease at the beginning of a contraction owing to head compression.