Question

A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error?

Answer 1

Correct Answers:

Nurse

Rationale :

While the healthcare provider is responsible for prescribing the medication, the nurse is ultimately responsible for verifying the medication order before administering it. If there is any uncertainty or ambiguity regarding the order, the nurse must clarify it with the provider to prevent errors. Nurses are responsible for ensuring the right dose is administered to the patient. Even if the prescription is unclear, the nurse has an obligation to verify the correct dosage before proceeding with the medication administration.

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Answer 2

Correct Answers:

Scatter rugs are present in the kitchen_

Rationale :

Scatter rugs in the kitchen or any area can pose a safety risk, particularly for clients with vision impairment. These rugs can create a tripping hazard, especially if the client is not able to see them clearly. This can lead to falls and serious injuries, which are a significant concern for older adults, particularly those with impaired vision due to glaucoma.

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Answer 3

Correct Answers:

Nausea

Rationale :

Subjective data refers to information provided by the client regarding their feelings, perceptions, and experiences that cannot be directly observed or measured by the nurse. Nausea is a subjective symptom because it is based on the client's personal experience and is not something the nurse can observe directly. In contrast, petechiae, blood pressure, and cyanosis are objective data that the nurse can observe or measure.

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Answer 4

Correct Answers:

Blood pressure sitting 130/60; blood pressure 110/60 standing

Rationale :

Orthostatic hypotension is diagnosed when a person's blood pressure decreases significantly upon standing. Typically, a drop in systolic pressure of 20 mmHg or more or a drop in diastolic pressure of 10 mmHg or more upon standing is considered indicative of orthostatic hypotension. In this case, the patient's blood pressure drops from 130/60 while sitting to 110/60 while standing, showing a decrease in systolic pressure by 20 mmHg, which confirms orthostatic hypotension.

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Answer 5

Correct Answers:

Presence of blood in the stool

Rationale :

The presence of blood in the stool of a patient with an ileostomy is concerning and should be reported immediately, as it may indicate complications such as gastrointestinal bleeding, infection, or injury to the stoma or surrounding tissue. The other options (continuous output, malodorous stool, and liquid consistency) can be expected and do not require immediate intervention unless there is a change in the patient's condition.

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Answer 6

Correct Answers:

35 mg/dL

Rationale :

The BUN (Blood Urea Nitrogen) level is often elevated in cases of dehydration, as the kidneys retain urea when there is reduced fluid volume. The normal range for BUN is 10-20 mg/dL. In a dehydrated client, the BUN level is likely to be above the normal range, typically between 20-40 mg/dL. A level of 35 mg/dL would be consistent with dehydration. The other values, such as 165 mg/dL, are much higher and would suggest a more severe condition or renal impairment.

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Answer 7

Correct Answers:

Hold the cane on the right side to provide support for the weaker leg

Rationale :

When using a cane, the client should hold the cane on the stronger side (in this case, the right side) to provide support for the weaker leg (left leg). This helps improve balance and stability. The cane should be held with the stronger hand to provide support for the weaker leg while walking. The other options are incorrect: removing the rubber tip could cause slipping, advancing the right leg and cane together could cause imbalance, and the cane should generally be placed about 15-25 cm (6-10 inches) in front of the feet, not 61 cm.

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Answer 8

Correct Answers:

Install flashing lights for alarms.

Rationale :

For a client with full hearing loss, visual signals, such as flashing lights, are a more effective way to alert them to important events like alarms, doorbells, or phone calls. This ensures the client’s safety and ability to respond to these signals, which might otherwise be missed due to the hearing loss. The other options (moving in with a family member, getting a roommate, or increasing sound on alarms) do not address the client's specific need for alternative communication or alerting methods in the home.

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Answer 9

Correct Answers:

Partial-thickness skin loss with red tissue in wound bed

Rationale :

A stage 2 pressure injury is characterized by partial-thickness skin loss involving the epidermis and/or dermis. The wound bed may appear as a shallow open ulcer, and the tissue in the wound bed is usually red or pink. There may also be intact or ruptured blisters. Stage 2 does not involve full-thickness loss or exposure of underlying structures like bone or muscle.

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Answer 10

Correct Answers:

Weak pulse

Rationale :

Hypovolemia refers to a condition where there is a decreased volume of blood in the body, which can be caused by blood loss. As the body compensates for the decreased blood volume, the heart pumps faster to maintain adequate circulation. However, due to the low blood volume, the pulse often becomes weak, especially in peripheral areas. This is a common sign of hypovolemia.

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Nurs 100 Fundamental Final Exam

No.

1 : A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error?

2 : A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma.

Which of the following findings should the nurse identify as a safety risk?

3 : A nurse is completing a client history and physical examination.

Which of the following information should the nurse consider subjective data?

4 : A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?

5 : The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?

6 : A nurse is admitting a client who is dehydrated. Which BUN level should the nurse expect the client to have upon admission

(Normal BUN 10-20)?

7 : A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

8 : The nurse is caring for a client with full hearing loss. What should the nurse recommend for the home environment?

9 : A nurse is assessing a client who has a stage 2 pressure injury.

Which of the following findings should the nurse expect?

10 : A nurse is caring for a client who sustained blood loss. Which is a manifestation of hypovolemia?

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Nurs 100 Fundamental Final Exam

No.

1 : A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error?

2 : A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma.Which of the following findings should the nurse identify as a safety risk?

3 : A nurse is completing a client history and physical examination.Which of the following information should the nurse consider subjective data?

4 : A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension?

5 : The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?

6 : A nurse is admitting a client who is dehydrated. Which BUN level should the nurse expect the client to have upon admission(Normal BUN 10-20)?

7 : A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

8 : The nurse is caring for a client with full hearing loss. What should the nurse recommend for the home environment?

9 : A nurse is assessing a client who has a stage 2 pressure injury.Which of the following findings should the nurse expect?

10 : A nurse is caring for a client who sustained blood loss. Which is a manifestation of hypovolemia?

2 : A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma.

Which of the following findings should the nurse identify as a safety risk?

3 : A nurse is completing a client history and physical examination.

Which of the following information should the nurse consider subjective data?

6 : A nurse is admitting a client who is dehydrated. Which BUN level should the nurse expect the client to have upon admission

(Normal BUN 10-20)?

9 : A nurse is assessing a client who has a stage 2 pressure injury.

Which of the following findings should the nurse expect?