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A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
- A. Assess the biopsy site.
- B. Take vital signs every hour.
- C. Assess urine for hematuria.
- D. Place the client in a prone position.
- E. Assess the client for chest pain.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
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The nurse overhears a surgical team member discussing a client's procedure in the hospital cafeteria. The nurse should:
- A. Report the breach to the hospital's privacy officer.
- B. Confront the team member immediately.
- C. Document the incident in the client's chart.
- D. Ignore the conversation as it was unintentional.
Correct Answer: A
Rationale: Discussing client information in a public area violates HIPAA. Reporting to the privacy officer ensures proper handling of the confidentiality breach.
A client will receive I.V. midazolam hydrochloride (Versed) during surgery. Which of the following should the nurse determine as a therapeutic effect?
- A. Amnesia.
- B. Nausea.
- C. Mild agitation.
- D. Blurred vision.
Correct Answer: A
Rationale: Midazolam's primary therapeutic effect is amnesia, reducing recall of surgical events. Nausea, agitation, and blurred vision are potential side effects, not desired outcomes.
There has been an increase in medication errors and errors in ordering laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which of the following situations? Select all that apply.
- A. When a medication order or critical lab result is received with the current or critical lab result is received.
- B. When any verbal or phone order is received.
- C. Whenever a written order or printed critical test result is received.
- D. When the unit secretary takes a phone order.
- E. When the agency uses computerized health care records.
Correct Answer: A,B,D
Rationale: Read-back procedures are required for verbal, phone, or critical result communications to ensure accuracy, especially when relayed through staff like unit secretaries.
Which of the following is an appropriate expected outcome for a client recovering from a total laryngectomy? The client will:
- A. Regain the ability to taste and smell food.
- B. Demonstrate appropriate care of the gastrostomy tube.
- C. Communicate feelings about body image changes.
- D. Demonstrate sterile suctioning technique for stoma care.
Correct Answer: C
Rationale: Communicating feelings about body image changes is an appropriate psychosocial outcome post-laryngectomy, addressing adaptation to altered appearance. Taste and smell may be impaired long-term. Gastrostomy tubes are not always required. Sterile suctioning is a nursing task, not a client outcome.
Which symptom suggests bladder cancer recurrence?
- A. Painful urination.
- B. Frequent urination.
- C. Hematuria.
- D. Nocturia.
Correct Answer: C
Rationale: Hematuria is a common sign of bladder cancer recurrence.