Nokea
Legal prohibitions against sharing passwords are legally based on:
- A. The Security Rule
- B. The American Nurses Association's Code of Ethics
- C. The American Hospital's Patients' Bill of Rights
- D. The Autonomy Rule
Correct Answer: A
Rationale: Legal prohibitions against sharing passwords are based on the Security Rule of HIPAA, which mandates safeguards to protect electronic protected health information.
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A nurse is preparing to administer a blood transfusion. Which of the following actions should be taken to verify the blood product? Select all that apply.
- A. Check the client's blood type with another nurse
- B. Verify the client's wristband identification
- C. Ensure the blood bag is labeled with the client's name
- D. Confirm the expiration date on the blood bag
- E. Match the blood type on the bag with the physician's order
Correct Answer: A,B,D,E
Rationale: Two nurses must verify the client's blood type, wristband, blood bag expiration, and match the blood type to the order to prevent transfusion reactions. The bag is labeled with a unit number, not the client's name.
The client scheduled for a transurethral resection prostatectomy (TURP) asks the nurse to explain how the prostate is going to be removed. The nurse should tell the client that the prostate will be removed through which pathway?
- A. The urethra
- B. A lower abdominal incision
- C. An upper abdominal incision
- D. An incision made in the perineal area
Correct Answer: A
Rationale: A TURP is done through the urethra. An instrument called a resectoscope is used to remove the tissue using high-frequency current. A lower abdominal incision is used for suprapubic or retropubic prostatectomy. An upper abdominal incision is not used. An incision between the scrotum and anus is made when a perineal prostatectomy is performed.
Which of the following actions is most appropriate when dealing with a client who is beginning to express anger verbally, is pacing, and is irritable?
- A. Conveying empathy and encouraging ventilation.
- B. Using calm, firm directions to get the client to a quiet room.
- C. Putting the client in restraints.
- D. Discussing alternative strategies for when the client is angry in the future.
Correct Answer: B
Rationale: Calm, firm directions to a quiet room de-escalate the situation, providing a safe environment for the client to calm down.
An older client has been prescribed casanthranol on a long-term basis to treat constipation. The nurse determines that which laboratory finding is a result of the side/adverse effects of this medication?
- A. Sodium 135 mEq/L (135 mmol/L)
- B. Sodium 145 mEq/L (145 mmol/L)
- C. Potassium 3.1 mEq/L (3.1 mmol/L)
- D. Potassium 5.0 mEq/L (5.0 mmol/L)
Correct Answer: C
Rationale: Hypokalemia can result from long-term use of casanthranol, which is a laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. The normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The normal range for sodium is 135 to 145 mEq/L (135 to 145 mmol/L). The remaining options all suggest normal values.
A client with a diagnosis of breast cancer is prescribed exemestane (Aromasin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of exemestane requiring immediate reporting.