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While giving a shift report on your assigned client, you realize that you forgot to record a nursing procedure done on your client. Which of the following methods of documentation would be best on your part?
- A. Write the procedure between the two lines of your shift documentation closest to the occurrence.
- B. Find a blank space in your earlier charting, and chart the procedure in that space.
- C. Tell the oncoming nurse to chart the procedure for you and to cite the time it was done.
- D. Chart the current date and time and 'Late entry,' indicating when and what was done.
Correct Answer: D
Rationale: A late entry with current date, time, and details of the missed procedure is best, maintaining accuracy and legality. Inserting between lines or blank spaces risks confusion, and delegating falsifies records. This method ensures transparency, critical for nursing accountability and care continuity.
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The nurse checked Mr. Gary's dose to prevent an overdose. This is an example of?
- A. Nonmaleficence
- B. Beneficence
- C. Fidelity
- D. Veracity
Correct Answer: A
Rationale: Checking dose to prevent overdose is nonmaleficence (A) avoiding harm, per ethics. Beneficence (B) does good, fidelity (C) keeps promises, veracity (D) tells truth not harm-specific. A fits the nurse's focus on safety, ensuring no adverse effects occur, aligning with nonmaleficence's protective principle, making it correct.
You are caring for a client who has just returned from surgery and has received intravenous morphine minutes before leaving the recovery room. You need to assess the client's pain now and again at which of the following times?
- A. in 20 to 30 minutes
- B. in one hour
- C. in two hours
- D. in 3 to 4 hours
Correct Answer: A
Rationale: Post-morphine pain assessment at 20-30 minutes evaluates peak effect, critical post-surgery. Later checks miss this window. Nurses time this for efficacy.
Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair?
- A. Bend at the waist and place arms under the client's arms and lift
- B. Face the client, bend knees and place hands on client's forearm and lift
- C. Spread his or her feet apart
- D. Tighten his or her pelvic muscles
Correct Answer: B
Rationale: Facing the client, bending knees, and using forearms provides a wide base and proper body mechanics for safe lifting.
A patient develops red eyes 2 days after an episode of malaria probable cause is:
- A. Conjunctivitis
- B. Anterior uveitis
- C. Viral keratitis
- D. Endophthalmitis
Correct Answer: B
Rationale: Red eyes post-malaria suggest an ocular complication. Conjunctivitis (choice A) causes redness but isn't typically linked to malaria unless secondary infection occurs. Anterior uveitis (choice B), inflammation of the iris and ciliary body, is a rare but documented malaria sequel, possibly from immune response or parasite-related damage, presenting with redness, pain, and photophobia. Viral keratitis (choice C) affects the cornea and is unrelated to malaria. Endophthalmitis (choice D), a severe intraocular infection, is unlikely without trauma or surgery. B is correct, as anterior uveitis aligns with malaria's systemic inflammatory effects. Nurses should assess eye symptoms, refer to ophthalmology, and manage pain, preventing vision loss in such cases.
A nurse must possess several characteristics to be successful in this profession. Secondary to critical thinking skills, which is of great value?
- A. Good teamwork and team-building skills
- B. A master's degree
- C. The ability to delegate responsibilities
- D. Advocating for the client at all times
Correct Answer: D
Rationale: Beyond critical thinking, advocating for the client at all times is a cornerstone of nursing success, reflecting the profession's core commitment to patient welfare. This involves ensuring clients' needs, rights, and preferences are prioritized in all care decisions, fostering trust and empowerment. Good teamwork and team-building skills are valuable for collaboration but are learned and applied contextually, not as intrinsic as advocacy. A master's degree enhances expertise but isn't required for foundational success, as many nurses excel with lesser credentials. Delegation is a skill that supports efficiency, yet it's secondary to the nurse's role as a client advocate. Advocacy drives nursing's caring ethos, addressing health needs across diverse settings and populations, making it a vital characteristic that complements critical thinking in achieving optimal outcomes and upholding professional integrity.