A nurse is documenting at a computer when a second nurse asks to use the computer to quickly document data before taking a break. Which of the following actions should the first nurse take?

Allow the second nurse to enter the data while observing them.

Log off the computer and let the second nurse log on and enter the data.

Ask the second nurse for the data and enter it for them

Tell the second nurse to enter the data when they return from their break.

Answer and Explanation

The Correct Answer is B

A. Allow the second nurse to enter the data while observing them. Even if observed, allowing another person to use a computer while logged in under someone else’s credentials violates HIPAA and security policies.
B. Log off the computer and let the second nurse log on and enter the data. This is the correct and secure action. Each nurse must use their own login to ensure accountability and protect patient confidentiality, as required by HIPAA and institutional policies.
C. Ask the second nurse for the data and enter it for them. This may lead to documentation errors or confusion about who provided care. Each nurse should document their own assessments and interventions.
D. Tell the second nurse to enter the data when they return from their break. While delaying documentation is sometimes necessary, timely documentation is important for safe patient care. The second nurse should have the opportunity to chart promptly, but under their own credentials.

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Correct Answer is B

Explanation

A. Initiate an oxytocin IV infusion. Oxytocin may be used to augment labor, but it should not be started immediately without first assessing maternal and fetal well-being. Continuous monitoring is necessary before initiating any uterotonic agent.
B. Apply a fetal heart rate monitor. After rupture of membranes, assessing the fetal heart rate is critical to detect signs of umbilical cord prolapse or fetal distress. Continuous electronic fetal monitoring helps evaluate the baby's response to labor.
C. Initiate fundal massage. Fundal massage is performed after delivery of the placenta to help contract the uterus and reduce postpartum bleeding. It is not appropriate during active labor.
D. Insert an indwelling urinary catheter. A catheter may be placed if necessary during labor, especially before epidural anesthesia, but it is not the immediate priority following membrane rupture. Fetal monitoring takes precedence.

A. "You should take a dose every night at bedtime." B. “You should take this medication with food." C. "You may repeat a dose after five minutes." D. “You may crush this medication if needed"

Correct Answer is C

Explanation

A. "You should take a dose every night at bedtime." Sublingual nitroglycerin is not taken on a routine schedule like bedtime. It is used as needed at the onset of chest pain or before activities that might trigger angina, not as a preventive nightly dose.
B. “You should take this medication with food." Sublingual nitroglycerin is placed under the tongue and absorbed directly into the bloodstream, bypassing the gastrointestinal system. It does not require administration with food.
C. "You may repeat a dose after five minutes." If chest pain persists after the first dose, the client may take one tablet every 5 minutes, up to a total of three doses within 15 minutes. If the pain continues after the third dose, emergency services should be contacted.
D. “You may crush this medication if needed." Sublingual tablets should never be crushed or swallowed, as this would prevent proper absorption through the oral mucosa and reduce the medication’s effectiveness in relieving acute chest pain.

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A nurse is documenting at a computer when a second nurse asks to use the computer to quickly document data before taking a break. Which of the following actions should the first nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is teaching a client about self-administration of sublingual nitroglycerin. Which of the following statements should the nurse include?

Correct Answer is C

Explanation

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