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A client has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?
- A. Discard the first voiding.
- B. Keep the urine in a single container on ice.
- C. Include the last voiding in the collection.
- D. Instruct the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
Correct Answer: A
Rationale: The correct action for the nurse to take when a client has a prescription for a 24-hour urine collection is to discard the first voiding. This initial voiding is typically not collected to allow for the accurate start of the 24-hour collection period. All subsequent urine voided within the specified time frame is then collected. Including the last voiding in the collection is important to ensure that the full 24-hour period is covered. It is essential to keep the urine cool by storing it in a single container on ice to prevent degradation of components. Instructing the client to stop midstream and finish urinating into the specimen container is not required for a 24-hour urine collection and is an unnecessary step.
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A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?
- A. "Get up and change positions slowly."
- B. "Avoid eating aged cheese and smoked meat."
- C. "Report any unusual bruising or bleeding to the doctor immediately."
- D. "Eat the same amount of foods that contain vitamin K every day."
Correct Answer: A
Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.
A healthcare professional is reviewing a client's health record and notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?
- A. Single
- B. Stat
- C. Routine
- D. Now
Correct Answer: C
Rationale: A routine prescription, such as lisinopril 10 mg PO once daily, is administered on a regular schedule with or without a termination date. It is a standard, ongoing prescription for maintenance therapy. Choice A, 'Single,' would typically refer to a one-time prescription. Choice B, 'Stat,' is used for prescriptions that are needed immediately or in emergency situations. Choice D, 'Now,' is not a common prescription type designation and is not applicable in this context.
A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?
- A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse.
- B. A nurse asks a nurse from another unit to assist with her documentation.
- C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care.
- D. A nurse discusses a client's status with the physical therapist who is caring for the client at the bedside.
Correct Answer: B
Rationale: The correct answer is B. HIPAA guidelines specify that only healthcare professionals directly involved in a patient's care should access their medical information. Asking a nurse from another unit to assist with documentation involves sharing patient information with someone not directly caring for the patient, which violates HIPAA guidelines. Choices A, C, and D involve individuals directly involved in the client's care, making them appropriate actions in line with HIPAA regulations. Choice A involves educating a nursing student under the supervision of the nurse, which is permissible. Choice C involves communicating with the client's designated healthcare decision-maker, which is also allowed under HIPAA. Choice D involves discussing the client's status with another healthcare professional directly involved in the client's care, which is within HIPAA guidelines.
A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
- A. Abnormal breath sounds
- B. Cyanosis of the lips
- C. Increasing pulse rate
- D. Pulse oximeter reading of 92%
Correct Answer: C
Rationale: An increasing pulse rate can be an early sign of poor oxygenation as the body tries to compensate. Abnormal breath sounds (choice A) can indicate respiratory issues, but they may not always be an early sign of poor oxygenation. Cyanosis of the lips (choice B) is a late sign of inadequate oxygenation. A pulse oximeter reading of 92% (choice D) indicates mild hypoxemia but may not be considered an early indication of poor oxygenation.
A client has a new cast on the left arm, and the nurse is assessing the client. Which of the following findings should the nurse report to the provider immediately?
- A. Increased warmth in the affected arm
- B. Itching under the cast
- C. Pain with passive movement
- D. Drainage on the cast
Correct Answer: C
Rationale: The correct answer is C: Pain with passive movement. Pain with passive movement in a client with a new cast can indicate compartment syndrome, a serious condition where pressure builds up within the muscles, nerves, and blood vessels of the affected limb, potentially leading to tissue damage. Immediate reporting is crucial to prevent further complications. Increased warmth in the affected arm could be a normal inflammatory response to the injury and casting process. Itching under the cast is common and can be managed without immediate concern. Drainage on the cast may be expected initially after casting due to residual moisture from the setting process, but ongoing or excessive drainage should be monitored and reported if persistent.