Nokea
A post-operative client with an abdominal wound tries to reach over and take a book off the bedside table. He immediately screams and calls for the nurse. The nurse notices serosanguineous drainage coming from the incision on the abdomen. The first action the nurse should take is to
- A. cover the incision with a sterile cloth or dressing.
- B. lower the head of the bed to less than 10 degrees.
- C. check the client's vitals to assess for drop in blood pressure.
- D. call and alert the surgeon.
Correct Answer: A
Rationale: Covering the incision with a sterile dressing prevents contamination and infection, which is the immediate priority. Assessing vitals or notifying the surgeon follows after stabilizing the wound.
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The physician has ordered Amoxil (amoxicillin) 500 mg capsules for a client with esophageal varices. The nurse can best care for the client's needs by:
- A. Giving the medication as ordered
- B. Providing extra water with the medication
- C. Giving the medication with an antacid
- D. Requesting an alternate form of the medication
Correct Answer: D
Rationale: Capsules can be difficult to swallow and may lodge in esophageal varices, increasing the risk of bleeding. An alternate form, such as a liquid, is safer.
The nurse is caring for a Muslim client who is recovering from an automobile accident and is unable to cleanse herself after a bowel movement. Which of the following should the nurse do to show respect for the woman's cultural and religious beliefs?
- A. Use the left hand to cleanse the client's rectal area.
- B. Ask a female family member to assist the client.
- C. Wear gloves when cleansing the client's rectal area.
- D. Ask the client's husband to assist the client.
Correct Answer: B
Rationale: In Islamic culture, hygiene after defecation is important, and female clients may prefer assistance from female family members (B) to maintain modesty. The left hand (A) is traditionally used by the client, not the nurse. Gloves (C) are standard but not cultural. The husband (D) may not be appropriate due to modesty.
The nurse is caring for a group of clients in an alcohol rehabilitation facility. A local news station is doing a story on addiction, and a representative comes to the facility, asking to interview a client. A client agrees to appear in the story, and the crew films an interview in the dayroom, showing a glimpse of other clients. Which violation has the nurse committed?
- A. allowing clients in a substance abuse facility to be interviewed by the media
- B. violating the HIPAA need to know rule
- C. releasing information about a minor without parental consent
- D. There is no violation.
Correct Answer: B
Rationale: The nurse violated HIPAA by allowing the filming of other clients without their consent, as this discloses protected health information (PHI) without authorization.
The nurse is seeing a client in the clinic who has shingles (herpes zoster). The client is concerned about spreading the disease to others. How should the nurse respond?
- A. It is only possible to have one episode of the disease.
- B. Persons with leukemia are at higher risk.
- C. Persons of all ages should receive the zoster vaccine (Zostavax).
- D. Persons between 30 and 40 years old are at high risk.
Correct Answer: B
Rationale: Shingles is contagious to immunocompromised individuals, such as those with leukemia, via contact with active lesions. The vaccine is recommended for older adults, not all ages, and recurrence is possible.
The nurse has documented a treatment on the wrong client's record. Which of the following methods of indicating the error is correct?
- A. The nurse draws a straight line through the incorrect entry and writes 'error' above it and initials the correction.
- B. The nurse uses correction fluid to cover the incorrect entry.
- C. The nurse draws multiple lines through the incorrect entry so it is unreadable, writes 'error' above it, and initials the correction.
- D. The nurse leaves the incorrect entry in place, writes 'error' in the margin, and initials and dates the notation.
Correct Answer: A
Rationale: A single line through the error with 'error' written above and initialed (A) maintains transparency while correcting the record. Correction fluid (B) is unacceptable, multiple lines (C) obscure the record, and margin notes (D) are insufficient.