Nokea
Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?
- A. When a family member offers information about their loved one
- B. When the client threatens self-harm and harm to others
- C. When the provider requests a copy of the client's history
- D. When a visitor insists that the visitor has been given permission by the client
Correct Answer: B
Rationale: When the client threatens self-harm and harm to others. Confidentiality can be breached to ensure safety, per legal precedents like the Tarasoff decision.
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A spansule is ordered twice a day for a client in the outpatient clinic. What should the nurse teach the client about taking a spansule?
- A. Take the spansule before breakfast and dinner.
- B. If the spansule is difficult to swallow, open it up and put the contents in food.
- C. Spansules should be taken at 12-hour intervals.
- D. Spansules can safely be cut for partial doses.
Correct Answer: C
Rationale: Spansules are time-release capsules, requiring 12-hour intervals for consistent drug release. Opening, cutting, or meal-based timing disrupts their mechanism.
A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm³, WBC 3,000/mm³, Hgb 9.3 g/dL, platelets 50,000/mm³.
The nurse would expect the patient to exhibit which of the following symptoms?
- A. BP 120/70, pulse 100, respirations 16.
- B. Ankle edema and ascites.
- C. Flushed face and light stools.
- D. Nausea, anorexia, and vomiting.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the situation. (1) correct-increased pulse and respirations are caused by decreased oxygenation of tissues (2) no information to suggest this is provided in the question (3) will be pale due to anemia, normal RBC male 4.3-5.9 million/mm³, female 3.5-5.5 million/mm³, decreased with anemia; normal WBC 4,500-11,000/mm³, decreased (leukopenia) causes susceptibility to infection; normal Hgb - male 13.5-17.5 g/dL, female 12-16 g/dL, decreased with anemia (4) not related to information provided in the question
A client with chronic obstructive pulmonary disease is receiving $\mathrm{O}_2$ at $3 \mathrm{~L}/\mathrm{min}$ via nasal cannula. He is anxious and short of breath, and his mental status is clouded. The nurse should:
- A. Increase the $\mathrm{O}_2$ to $6 \mathrm{~L}/\mathrm{min}$.
- B. Monitor for signs of impending respiratory failure.
- C. Maintain the $\mathrm{O}_2$ at $3 \mathrm{~L}/\mathrm{min}$, but increase the humidity.
- D. Check the vital signs and oxygen saturation level.
Correct Answer: D
Rationale: Checking vital signs and oxygen saturation assesses the cause of symptoms (e.g., hypoxia, hypercapnia). Increasing O2 risks CO2 retention in COPD. Monitoring is passive. Humidity is secondary.
A 21-year-old primipara in active labor.
The nurse observes a new graduate nurse palpating the uterine contractions of a 21-year-old primipara in active labor. Which of the following actions, if taken by the new graduate nurse, is MOST appropriate?
- A. The graduate nurse places the palm of one hand on the fundus and moves the hand around the abdomen.
- B. The graduate nurse places the heels of both hands on the lower abdomen and presses lightly.
- C. The graduate nurse places one hand on the abdomen over the fundus and with the fingertips, presses gently.
- D. The graduate nurse places the palms of the hands on either side of the abdomen and presses firmly.
Correct Answer: C
Rationale: Strategy: 'MOST appropriate' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) palpations should be done with fingertips, not palms of hands (2) palpations should be done with fingertips, not heels of hands (3) correct-done with fingertips (4) palpations should be done with fingertips, not palms of hands
What is the most important consideration when teaching parents how to reduce risks in the home?
- A. Age and knowledge level of the parents
- B. Proximity to emergency services
- C. Number of children in the home
- D. Age of children in the home
Correct Answer: D
Rationale: Age of children in the home. Safety measures must be tailored to the developmental stage of the children.