Nokea
Which nursing action(s) can result in disciplinary action by state boards of nursing?
- A. Release of client health information to a client's neighbor
- B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
- C. Release of client health information to the client's durable power of attorney
- D. A, B
Correct Answer: D
Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals, such as a client's neighbor (choice A) or improper delegation of nursing tasks to unlicensed personnel like UAPs (choice B), are violations of patient confidentiality and safety. Releasing client health information to the client's durable power of attorney (choice C) is a legal and appropriate action, not warranting disciplinary action. Therefore, choices A and B can result in disciplinary action by state boards of nursing, making option D the correct answer.
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The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?
- A. Assess the client's vital signs
- B. Start an IV with an 18-gauge needle
- C. Begin iced saline lavage
- D. A, B
Correct Answer: D
Rationale: In this scenario, the client's presentation of acute epigastric pain and vomiting bright red blood indicates a potential gastrointestinal bleeding emergency. Assessing the client's vital signs is essential to monitor their hemodynamic status. Starting an IV with an 18-gauge needle is crucial to establish access for potential fluid resuscitation or blood transfusion. Beginning iced saline lavage is not appropriate in this situation and could potentially delay necessary interventions. Therefore, the correct interventions for the nurse to implement are to assess the client's vital signs and start an IV, making option D the most appropriate choice. Options A and B are correct because they are essential initial steps in managing gastrointestinal bleeding. Option C is incorrect as iced saline lavage is not indicated and may not address the urgent needs of the client in this critical situation.
The client has failed to conceive after many attempts over a three-year time period and asks the nurse, "I have tried everything. What should I do now?" Which statement is the nurse's best response?
- A. Assess the intravenous fluids for rate and volume
- B. Change the surgical dressing every day at the same time
- C. Monitor the client's medication levels daily
- D. Monitor the percentage of each meal eaten
Correct Answer: A
Rationale: The correct response is to assess the intravenous fluids for rate and volume. In this situation, the client is seeking guidance on fertility issues, not related to intravenous fluids, surgical dressing changes, medication levels, or meal monitoring. The nurse should provide supportive and empathetic guidance, suggesting further options like consulting fertility specialists or exploring additional treatments.
A patient with chronic renal failure should avoid which of the following?
- A. Potassium
- B. Calcium
- C. Iron
- D. Zinc
Correct Answer: A
Rationale: Patients with chronic renal failure should avoid potassium due to impaired kidney function. The kidneys play a crucial role in regulating potassium levels in the body. In renal failure, the kidneys may not be able to excrete excess potassium effectively, leading to hyperkalemia. Calcium, iron, and zinc are not typically restricted in chronic renal failure unless there are specific individual circumstances, making them incorrect choices.
Enteral feedings may be appropriate for patients with:
- A. Acute cholecystitis
- B. Hepatic encephalopathy
- C. Ulcerative colitis in remission
- D. Acute exacerbation of Crohn's disease
Correct Answer: D
Rationale: Enteral feedings are commonly utilized for patients experiencing acute exacerbations of Crohn's disease to provide necessary nutrition and rest the bowel. Choices A, B, and C are incorrect because enteral feedings are not typically indicated for acute cholecystitis, hepatic encephalopathy, or ulcerative colitis in remission.
When a field medical element is not operational, it engages in training to achieve readiness for mobilization that involves all aspects of operation. Individuals must be proficient in their MOS/ASI and which of the following?
- A. Command and control procedures
- B. Computers and data processing
- C. Common soldier tasks
- D. Communications and automation
Correct Answer: C
Rationale: In this scenario, when a field medical element is not operational, training is essential to prepare for mobilization. Proficiency in MOS/ASI (Military Occupational Specialty/Area of Specialization) is crucial, along with proficiency in common soldier tasks. Common soldier tasks encompass fundamental skills and knowledge that are essential for operational readiness and mobilization. Options A, B, and D are not as directly related to individual readiness for mobilization in this context.