A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's indwelling urinary catheter but forgets to unclamped it. The patient develops a urinary tract infection. What do the nurse's actions' exemplify ?

Correct Answer: D

Rationale: The nurse's actions exemplify negligence. Negligence is a failure to provide reasonable care that results in harm to a patient. In this scenario, the nurse failed to unclamp the patient's indwelling urinary catheter as instructed by the healthcare provider. This failure to follow proper procedure led to the patient developing a urinary tract infection, which could have been prevented if the nurse had acted with reasonable care. This action does not meet the criteria for malpractice, assault, or battery as those involve intentional harm or professional misconduct, whereas negligence involves a lack of appropriate care or attention.

Correct Answer: B

Rationale: The laboratory test used to monitor the therapeutic effect of warfarin therapy is the International Normalized Ratio (INR). Warfarin is a commonly prescribed anticoagulant medication that works by inhibiting the action of vitamin K-dependent clotting factors. Maintaining the INR within the target range specific to the indication for anticoagulation (e.g., DVT prevention or treatment) is essential to balance the risk of bleeding and clotting.

Correct Answer: C

Rationale: The first action the nurse should take when a patient post-thyroidectomy develops signs of hypocalcemia is to assess the patient's calcium level. By assessing the patient's calcium level through laboratory testing, the nurse can confirm the presence of hypocalcemia and determine the severity of the condition. This information will guide further interventions, such as administering calcium supplements or notifying the healthcare provider for additional management. It is important to confirm the diagnosis before proceeding with treatment to ensure appropriate and safe care for the patient.

Correct Answer: D

Rationale: Confusion is a potential adverse effect of digoxin therapy. Digoxin toxicity can manifest as various central nervous system symptoms, including confusion, delirium, and disorientation. It is important to monitor for signs of digoxin toxicity in patients taking this medication, especially those with a history of heart failure or renal impairment. Other common signs of digoxin toxicity may include visual disturbances (like halos around lights), gastrointestinal symptoms (like nausea and vomiting), and cardiac arrhythmias. Monitoring serum digoxin levels can help guide therapy and identify toxicity early.

Correct Answer: C

Rationale: Dry cough is the most commonly reported adverse effect associated with lisinopril therapy. Lisinopril is an ACE inhibitor, and the mechanism behind the cough is not completely understood but is thought to be related to the accumulation of bradykinin and substance P. This annoying dry cough can be a persistent issue for some patients on lisinopril, and it typically resolves once the medication is discontinued. Patients who experience this side effect should not ignore it and should consult their healthcare provider for further evaluation and possible alternative medication options. Hyperkalemia, hypertension, and bradycardia are not commonly associated adverse effects of lisinopril therapy.