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A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Tell the staff members to stop their discussion.
- C. Participate in an in-service about client confidentiality.
- D. Speak to the staff members in private about client confidentiality.
Correct Answer: B
Rationale: Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client's medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client's privacy is respected.
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A nurse is reinforcing teaching with a client who is scheduled for a tilt-table test. Which of the following instructions should the nurse include?
- A. Fast for 4 hours before the test.
- B. Wear tight-fitting clothing.
- C. Take a sedative before the test.
- D. Avoid drinking fluids during the test.
Correct Answer: A
Rationale: Fasting for 4 hours before a tilt-table test reduces the risk of nausea or vomiting during positional changes.
A nurse is reinforcing teaching with a client who has a new prescription for a fentanyl patch. Which of the following instructions should the nurse include?
- A. Apply the patch to the same site each time.
- B. Remove the patch after 24 hours.
- C. Apply the patch to broken skin.
- D. Dispose of the patch in a sharps container.
Correct Answer: D
Rationale: Disposing of the fentanyl patch in a sharps container or per facility protocol prevents accidental exposure to the potent opioid.
A nurse is caring for a client who has a new prescription for cyclobenzaprine. Which of the following adverse effects should the nurse monitor for?
- A. Drowsiness
- B. Weight gain
- C. Hyperglycemia
- D. Tinnitus
Correct Answer: A
Rationale: Cyclobenzaprine, a muscle relaxant, commonly causes drowsiness, which can affect safety and coordination.
A nurse is reinforcing teaching with a client who is scheduled for an electroencephalogram (EEG). Which of the following instructions should the nurse include?
- A. Avoid caffeine before the procedure.
- B. Take your antiseizure medication as prescribed.
- C. Wash your hair after the procedure.
- D. Expect to be sedated during the procedure.
Correct Answer: A
Rationale: Avoiding caffeine before an EEG prevents stimulation that could alter brain wave patterns and affect results.
A nurse is caring for a client who has a new diagnosis of glaucoma. Which of the following findings should the nurse expect?
- A. Blurred vision
- B. Weight loss
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Blurred vision is a common symptom of glaucoma due to increased intraocular pressure affecting the optic nerve.