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A nurse enters the hallway and discovers a visitor looking at a client's medical information on a computer. Which of the following actions should the nurse take first?
- A. Inform the care nurse that a visitor viewed a client's protected health information.
- B. Close the documentation program on the computer.
- C. Inform the visitor that the client's records are confidential.
- D. Find out which staff member left the documentation program on the screen.
Correct Answer: B
Rationale: The correct first action for the nurse to take is to close the documentation program on the computer to prevent further unauthorized access to the client's medical information. Choice A is incorrect because the immediate concern is to secure the information first. Choice C, while important, can be addressed after securing the information. Choice D, finding out which staff member left the program open, is not the immediate priority when patient confidentiality is at risk.
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Your client has a doctor's order that reads 'advance diet as tolerated'. This client has returned from the recovery room after an appendectomy and he states, 'I am hungry'. What would you offer this client to consume?
- A. Cheese and crackers
- B. Apple sauce
- C. Chicken broth
- D. A peanut butter sandwich
Correct Answer: C
Rationale: Chicken broth is a suitable option for a post-appendectomy patient beginning to tolerate oral intake. It is clear liquid and easily digestible, making it a gentle choice for someone who has just returned from surgery. Cheese and crackers, apple sauce, and a peanut butter sandwich are not ideal options for an individual who needs to start with a light and easily digestible diet.
Which of the following actions can an individual nurse take to exert leadership in supporting the profession of nursing?
- A. Join a local professional organization.
- B. Talk about healthcare issues to everyone who will listen, including legislators.
- C. Register to vote.
- D. Learn about the healthcare system.
Correct Answer: B
Rationale: Engaging in conversations about healthcare issues with a wide audience, including legislators, is a powerful way for a nurse to exert leadership and support the nursing profession. This action helps raise awareness, advocate for nursing-related matters, and contribute to positive changes in healthcare policies. Choice A, joining a local professional organization, is beneficial but may not have the same broad impact as engaging in public discourse. Choice C, registering to vote, is important for civic engagement but does not directly relate to exerting leadership in supporting the nursing profession. Choice D, learning about the healthcare system, is valuable for personal development but does not directly address exerting leadership in supporting the nursing profession.
The nurse is planning care for a patient with acute hypernatremia. What should the nurse include in this patient's plan of care? (select one that does not apply)
- A. Reduce IV access
- B. Limit length of visits
- C. Restrict fluids to 1500 mL per day
- D. Conduct frequent neurologic checks
Correct Answer: D
Rationale: For a patient with acute hypernatremia, the nurse should include interventions like reducing free water losses, correcting sodium levels slowly, monitoring neurologic status, and ensuring adequate fluid intake. Conducting frequent neurologic checks is essential in assessing the patient's neurological status and detecting any changes promptly. Therefore, this action should not be excluded from the plan of care. Choices A, B, and C are not directly related to managing acute hypernatremia and can be safely excluded from the plan of care. Reducing IV access, limiting length of visits, and restricting fluids to 1500 mL per day are not appropriate actions for managing acute hypernatremia.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
- A. Generalized rash over trunk
- B. Increased temperature
- C. Decreased level of consciousness
- D. Report of photophobia
Correct Answer: C
Rationale: The correct answer is C: Decreased level of consciousness. In a client with meningitis, a decreased level of consciousness is a critical finding that should be reported immediately. This could indicate increased intracranial pressure or neurological deterioration, requiring prompt intervention. Choices A, B, and D are important in the assessment of meningitis but are not as immediately concerning as a decreased level of consciousness. A generalized rash over the trunk can be seen in meningococcal meningitis, an increased temperature is expected due to the inflammatory response, and photophobia is a common symptom due to meningeal irritation.
Which individual is most at risk for Osgood-Schlatter disease?
- A. An elderly female who is hospitalized with a hip fracture and on bed rest
- B. A middle-aged male patient who has been exposed to asbestos in the shipping industry
- C. An adolescent who is physically active and the captain of their soccer team
- D. An infant of low birth weight and a gestational age of 28 weeks
Correct Answer: C
Rationale: Osgood-Schlatter disease is a condition that commonly affects adolescents who are physically active, especially during growth spurts. It is caused by overuse of the knee, leading to inflammation of the patellar ligament at the tibial tuberosity. The repetitive stress on the growth plate during activities like running and jumping can trigger this condition. Therefore, an adolescent who is physically active and the captain of their soccer team is most at risk for Osgood-Schlatter disease. Choices A, B, and D are not at high risk for this condition as it is primarily seen in active adolescents.