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Questions 227

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Extract:


Question 1 of 5

While writing a report at 3:15 in the afternoon, the nurse realizes that she forgot to chart the client's physical therapy, which occurred at 10:30 A.M. Which is the appropriate action for the nurse to take?

Correct Answer: B

Rationale: A late entry with the correct time (10:30 A.M.) ensures accurate documentation, maintaining the integrity of the medical record.

Question 2 of 5

A client with paranoid personality disorder monopolizes group activities with complaints that the staff is out to get him. The nurse should:

Correct Answer: D

Rationale: One of the most therapeutic actions the nurse can take with the paranoid client is to spend time with him but not challenge his delusions. Answer A would challenge his delusions and make him more convinced that he is right, so it is incorrect. Answers B and C would isolate the client and increase his paranoid thinking, so they're incorrect.

Question 3 of 5

A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?

Correct Answer: D

Rationale: Morphine can cause sphincter of Oddi spasm, worsening pancreatitis pain, and should be questioned. Meperidine is preferred, and Mylanta/cimetidine are appropriate for symptom management.

Question 4 of 5

The physician writes an order for furosemide (Lasix) 120 mg. Each tablet contains 40 mg. How many tablets would you administer?

Correct Answer: C

Rationale: 120 mg ÷ 40 mg/tab = 3 tablets. Whole tablets are administered, and 3 tabs is exact. Other options are incorrect calculations or non-standard dosing.

Extract:

On the second day of surgery, the mother reported fever and rapid respirations on her child. The child's temperature was 39°C.


Question 5 of 5

The first action taken by the nurse should be to

Correct Answer: A

Rationale: Fever and rapid respirations post-surgery may indicate infection or complications, requiring immediate physician notification.

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