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A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
- A. Use wool blankets on your bed.
- B. Do not adjust the oxygen flow rate.
- C. Store unused oxygen tanks horizontally.
- D. Check your oxygen equipment once each week.
Correct Answer: B
Rationale: The correct answer is B: Do not adjust the oxygen flow rate. It is essential not to adjust the oxygen flow rate as it is prescribed by a healthcare provider based on the client's condition. Incorrectly adjusting the flow rate can lead to inadequate oxygen delivery or oxygen toxicity. Choice A is incorrect as wool blankets can generate static electricity, which can be dangerous around oxygen. Choice C is incorrect because oxygen tanks should be stored vertically to prevent accidents. Choice D is incorrect as oxygen equipment should be checked daily for safety and functionality.
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A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?
- A. This stage is when testing occurs to identify boundaries of interpersonal behaviors.
- B. Consensus evolves in this stage.
- C. This stage involves constructive efforts on the part of the group members.
- D. Resistance is evident as subgroups form in this stage.
Correct Answer: B
Rationale: The correct answer is B: Consensus evolves in this stage. During the norming stage of group development, members begin to resolve conflicts and establish norms and values. Consensus-building is crucial in this stage to ensure everyone is on the same page and working towards common goals. This process helps the group to develop cohesion and unity.
Choice A is incorrect because testing occurs in the forming stage, not norming. Choice C is incorrect because constructive efforts typically occur in the performing stage, not norming. Choice D is incorrect because resistance and subgroup formation usually happen in the storming stage, not norming.
A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hours as needed. The amount available is diphenhydramine elixir 12.5 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: Correct Answer: 2 mL
Rationale: To calculate the mL per dose, divide the prescribed mg by the concentration in mg/mL. 25 mg ÷ 12.5 mg/mL = 2 mL. This dosage ensures the correct amount of diphenhydramine is administered.
Summary of Other Choices:
A: Incorrect, as it does not calculate the dosage correctly.
B-G: Irrelevant as they do not provide any calculations or rationale for the correct dosage.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperglycemia
- C. Dehydration
- D. Polyphagia
Correct Answer: C
Rationale: The correct answer is C: Dehydration. In diabetes insipidus, there is a deficiency of antidiuretic hormone leading to excessive urine output, causing dehydration. Bradycardia (A) is not typically associated. Hyperglycemia (B) is seen in diabetes mellitus, not diabetes insipidus. Polyphagia (D) is excessive hunger, which is not a common symptom of diabetes insipidus.
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
- A. Hemorrhage
- B. Infection
- C. Urinary retention
- D. Pain
Correct Answer: A
Rationale: The correct answer is A: Hemorrhage. Postoperative hemorrhage is a critical complication following a transurethral resection of the prostate due to the rich blood supply in the area. It can lead to hypovolemic shock and requires immediate intervention to prevent further complications. Monitoring for signs of bleeding such as increased heart rate, decreased blood pressure, and decreased urine output is crucial.
B: Infection is an important complication to monitor for but is not as immediately life-threatening as hemorrhage.
C: Urinary retention can occur postoperatively but is not as urgent as hemorrhage.
D: Pain management is important for the client's comfort, but it is not the priority in this situation.
In summary, monitoring for hemorrhage is crucial as it is the most life-threatening complication that requires immediate attention compared to the other options.
A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?
- A. The ethics committee will need to approve this request for you.
- B. I will ask the nursing supervisor to obtain the medical records for you.
- C. The healthcare provider will share this information with you.
- D. The client must provide permission to share the records with you.
Correct Answer: D
Rationale: The correct response is D: The client must provide permission to share the records with you. This is the correct answer because under HIPAA regulations, a client's medical records are confidential and can only be shared with the client's explicit permission. The nurse cannot disclose the records to a family member without the client's consent. Option A is incorrect because the ethics committee does not handle individual requests for medical records. Option B is incorrect as the nursing supervisor cannot release medical records without proper authorization. Option C is incorrect as the healthcare provider cannot share the information without the client's consent.