Nokea
A throat culture is ordered for an adult who has a sore throat. The nurse asks the client if he has taken any medications to treat himself. Which medication, if reported by the client, would be of greatest concern to the nurse?
- A. Aspirin
- B. A throat lozenge
- C. Acetaminophen
- D. An antibiotic
Correct Answer: D
Rationale: Antibiotics can alter throat culture results by reducing bacterial growth, potentially leading to a false negative, the greatest concern.
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The precepting nurse supervising a graduate practical nurse would need to intervene when the graduate nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply.
- A. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement.
- B. Advises the client transport technician, 'This client has fragile bones due to cancer, so move the client very carefully.'
- C. Asks a client, 'When were you diagnosed with diabetes?' in a semi-private room with the privacy curtain in place between beds.
- D. Interprets the results of a client's diagnostic testing to the unit clerk
- E. Writes a client's last name and room number on a whiteboard hanging in the nurse's station on which scheduled procedures are logged
Correct Answer: A,D,E
Rationale: Accessing unassigned records , sharing results with a clerk , and writing names on a public whiteboard violate HIPAA. Sharing relevant care info and private questioning are permissible.
A client with hyperkalemia is to receive an infusion of $250 \mathrm{~mL}$ of $20% glucose with 20 units of regular insulin. The rationale for this therapy is:
- A. Potassium elimination is enhanced.
- B. Potassium binds with the glucose and is excreted by the kidneys.
- C. Glucose uptake by the cell drives the potassium into the cell.
- D. Insulin lowers the potassium by lowering blood glucose.
Correct Answer: C
Rationale: Insulin facilitates glucose uptake by cells, which drives potassium into cells, lowering serum potassium levels in hyperkalemia.
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant
- B. The infant is very susceptible to infections
- C. Growth and development patterns will proceed at a normal rate
- D. Careful monitoring of renal function is indicated
Correct Answer: B
Rationale: The infant is very susceptible to infections. HIV compromises the immune system, increasing susceptibility to opportunistic infections.
A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure?
- A. Abdominal rigidity and diarrhea
- B. Back pain and urge incontinence
- C. Difficulty swallowing and breathing
- D. Difficulty walking and hand tremor
Correct Answer: C
Rationale: Botulinum toxin can cause muscle weakness, leading to dysphagia and respiratory issues . Abdominal , urinary , or motor symptoms are not typical.
The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.
- A. I will apply moisturizing lotion on my legs every day.
- B. I will elevate my legs at night when I am sleeping.
- C. I will keep my legs below heart level when sitting.
- D. I will start walking outside with my neighbor.
- E. I will use a heating pad to promote circulation.
Correct Answer: A,C,D
Rationale: Moisturizing , keeping legs dependent , and walking improve skin and circulation. Elevation is for venous issues, and heating pads risk burns.