Nokea
An adult client in an acute care setting asks the nurse to show him his hospital records. The nurse's response should reflect which understanding?
- A. The client has no right to see his records without a court order.
- B. The client must have the physician's approval before he can see his records.
- C. The client has the right to see his records and to have information explained when necessary.
- D. The client must ask permission to view his records from the medical records department and must appear before a special committee.
Correct Answer: C
Rationale: HIPAA grants clients the right to access their medical records and receive explanations, ensuring transparency. Court orders, physician approval, or committees are not required.
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The nurse is providing home care for a client who is visually impaired. What safety precaution is most appropriate for this client?
- A. Remove scatter rugs.
- B. Have hand rails in the bathroom.
- C. Have side rails up whenever the client is in bed.
- D. Have a bell to call for help.
Correct Answer: A
Rationale: Removing scatter rugs prevents tripping, the most effective safety measure for a visually impaired client at home.
A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client?
- A. Capillary refill less than 3 seconds
- B. Pale mucous membranes
- C. Respirations 20 breaths per minute
- D. Complaints of fatigue when ambulating
Correct Answer: A
Rationale: Capillary refill less than 3 seconds. Since the hemoglobin and hematocrit are normal for an adult female, additional assessments should be normal. This capillary refill time is normal.
The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first
- A. Assess the client's airway
- B. Call for help
- C. Establish that the client is unresponsive
- D. See if anyone saw the client fall
Correct Answer: C
Rationale: Establish that the client is unresponsive. This is the first step in CPR to determine the need for further action.
A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?
- A. Maintaining proper body alignment
- B. Frequent neurovascular assessments of the affected leg
- C. Inspection of pin sites for evidence of drainage or inflammation
- D. Applying an over-bed trapeze to assist the client with movement in bed
Correct Answer: B
Rationale: The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage.
The nurse should monitor for which potential complication in a client receiving IV vancomycin and gentamicin?
- A. Blood in nasogastric tube drainage
- B. Decrease in red blood cell count
- C. Increase in serum creatinine level
- D. Onset of muscle aches and cramping
Correct Answer: C
Rationale: Vancomycin and gentamicin are nephrotoxic, so monitoring for increased serum creatinine is essential to detect kidney injury. GI bleeding , anemia , and muscle cramps are less directly related.