Nokea
A nurse is reviewing client confidentiality with other staff members. The nurse should identify which of the following actions is an example of protecting client confidentiality.
- A. Discarding worksheets containing client information in a wastebasket
- B. Writing a client's diagnosis on the message board in the client's room
- C. Giving change of shift report to a nurse outside the client's room
- D. Discussing a client's prognosis with an assistive personnel who is caring for the client
Correct Answer: C
Rationale: Giving a shift report in a private setting prevents unauthorized individuals from overhearing, protecting confidentiality. Discarding worksheets improperly, writing diagnoses publicly, or discussing prognosis openly risks breaches.
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A nurse is reinforcing teaching with a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?
- A. Take this medication every morning.
- B. You might experience a rapid heartbeat.
- C. You need to rinse your mouth after using this medication.
- D. You should use this medication to prevent asthma attacks.
Correct Answer: B
Rationale: Albuterol can cause tachycardia, a side effect to anticipate. It's used as needed, not daily, mouth rinsing is for steroids, and it treats, not prevents, attacks.
A nurse is caring for a client who is receiving IV fluids. Which of the following actions should the nurse take to prevent phlebitis?
- A. Change the IV site every 72 to 96 hr.
- B. Massage the IV site gently every 4 hr.
- C. Apply a cold compress to the IV site.
- D. Use a large-gauge catheter for fluid administration.
Correct Answer: A
Rationale: Changing the IV site every 72-96 hours reduces infection and phlebitis risk. Massaging, cold compresses, or large catheters don't prevent phlebitis.
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?
- A. Elevate the arm.
- B. Document the infiltration.
- C. Stop the infusion.
- D. Apply a warm compress.
Correct Answer: C
Rationale: Stopping the infusion is the priority to prevent further fluid infiltration, which can cause tissue damage. Elevation, documentation, and compresses follow after halting the infusion.
A nurse is reinforcing teaching with a client who has a new prescription for sertraline. Which of the following statements should the nurse include?
- A. You should take this medication in the morning.
- B. You might experience insomnia while taking this medication.
- C. You need to avoid caffeine while taking this medication.
- D. You should expect immediate improvement in your symptoms.
Correct Answer: B
Rationale: Sertraline can cause insomnia, a key side effect to anticipate. It's taken flexibly, caffeine isn't restricted, and effects take weeks.
A nurse is caring for a client who has a new prescription for digoxin. Which of the following actions should the nurse take?
- A. Check the client's potassium level.
- B. Administer the medication with a high-fiber meal.
- C. Instruct the client to take the medication at bedtime.
- D. Monitor the client's blood pressure every 4 hr.
Correct Answer: A
Rationale: Digoxin toxicity risks increase with hypokalemia, so potassium monitoring is essential. Fiber meals, bedtime dosing, or routine blood pressure checks aren't specific.