The nurse In-charge in labor and delivery unit administered a dose of
terbutaline to a client without checking the client's pulse. The standard
that would be used to determine if the nurse was negligent is: A. The
physician's orders.
B. The action of a clinical nurse specialist who is recognized expert in
the field.
C. The statement in the drug literature about administration of
terbutaline.
D. The actions of a reasonably prudent nurse with similar education and
expe-
rience: Answer: (D) The actions of a reasonably prudent nurse with
similar education and experience. The standard of care is determined by
the average degree of skill, care, and diligence by nurses in similar
circumstances.
Nurse Amy is aware that the following is true about functional nursing
A. Provides continuous, coordinated and comprehensive nursing
services.
B. One-to-one nurse patient ratio.
C. Emphasize the use of group collaboration.
D. Concentrates on tasks and activities.: Answer: (A) Provides
continuous, coordinated and comprehensive nursing services.
Functional nursing is focused on tasks and activities and not on the
care of the patients.
Which type of medication order might read "Vitamin K 10 mg I.M. daily ×
3 days?"
A. Single order
B. Standard written order
,C. Standing order
D. Stat order: Answer: (B) Standard written order. This is a standard
written order. Prescribers write a single order for medications given
only once. A stat order is written for medications given immediately for
an urgent client problem. A standing order, also known as a protocol,
establishes guidelines for treating a particular disease or set of
symptoms in special care areas such as the coronary care unit.
Facilities also may institute medication protocols that specifically
designate drugs that a nurse may not give.
A female client with a fecal impaction frequently exhibits which clinical
manifestation?
A. Increased appetite
B. Loss of urge to defecate
C. Hard, brown, formed stools
D. Liquid or semi-liquid stools: Answer: (D) Liquid or semi-liquid stools.
Passage of liquid or semi-liquid stools results from seepage of
unformed bowel contents around the impacted stool in the rectum.
Clients with fecal impaction don't pass hard, brown, formed stools
because the feces can't move past the impaction. These clients
typically report the urge to defecate (although they can't pass stool)
and a decreased appetite.
Nurse Linda prepares to perform an otoscopic examination on a female
client. For proper visualization, the nurse should position the client's ear
by:
A. Pulling the lobule down and back
B. Pulling the helix up and forward
C. Pulling the helix up and back
, D. Pulling the lobule down and forward: Answer: (C) Pulling the helix up
and back. To perform an otoscopic examination on an adult, the nurse
grasps the helix of the ear and pulls it up and back to straighten the
ear canal. For a child, the nurse grasps the helix and pulls it down to
straighten the ear canal. Pulling the lobule in any direction wouldn't
straighten the ear canal for visualization.
Which instruction should nurse Tom give to a male client who is having
external radiation therapy:
A. Protect the irritated skin from sunlight.
B. Eat 3 to 4 hours before treatment.
C. Wash the skin over regularly.
D. Apply lotion or oil to the radiated area when it is red or sore.: Answer:
(A) Protect
the irritated skin from sunlight. Irradiated skin is very sensitive and must
be protected with clothing or sunblock. The priority approach is the
avoidance of strong sunlight
In assisting a female client for immediate surgery, the nurse In-charge is
aware that she should:
A. Encourage the client to void following preoperative medication.
B. Explore the client's fears and anxieties about the surgery.
C. Assist the client in removing dentures and nail polish.
D. Encourage the client to drink water prior to surgery.: Answer: (C)
Assist the client in removing dentures and nail polish. Dentures,
hairpins, and combs must be removed. Nail polish must be removed
so that cyanosis can be easily monitored by observing the nail beds.