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The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions.Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?
- A. Shares the health history with case manager.
- B. Discusses diagnoses with the physical therapist.
- C. Provides a list of food allergies to nutritional services.
- D. Requests military records by phone.
Correct Answer: D
Rationale: Requesting military records by phone without the patient's consent would be a breach of confidentiality.
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A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections.Which intervention is most appropriate to prevent the spread of MRSA to others?
- A. Change coccyx dressing after performing routine care.
- B. Change coccyx dressing before performing routine care.
- C. Restate the vital importance of performing hand hygiene.
- D. Perform coccyx dressing change in the nursing station.
Correct Answer: C
Rationale: Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing.
The healthcare provider prescribes penicillin 800,000 units intramuscularly (IM) for a patient with a streptococcal infection. The vial available is labeled Penicillin 50,000 units/mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.).
- A. 10
- B. 12
- C. 14
- D. 16
Correct Answer: D
Rationale: The healthcare provider prescribed 800,000 units of penicillin and the vial available is labeled 50,000 units/mL. To calculate the number of mL to administer, you need to divide the total number of units prescribed (800,000) by the number of units per mL (50,000). This gives you a result of 16 mL.
An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments.What action should the nurse take first?
- A. Send the UAP to be educated on how to care for a foot ulcer.
- B. Advise the UAP to wear gloves when caring for the FP.
- C. Instruct the UAP to start with basic wound care precautions.
- D. Ask the UAP which action they would take first and state why.
Correct Answer: A
Rationale: It is important for the UAP to receive proper education and training on how to care for a foot ulcer before being assigned to care for a client with this condition.
The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.Which intervention should the nurse implement next?
- A. Ask the UAP to offer back rubs to the client.
- B. Reassess the client and the level of pain.
- C. Encourage the client to focus on taking deep breaths.
- D. Tell the client the medication needs more time to work.
Correct Answer: B
Rationale: The nurse should reassess the client's pain level and determine if additional interventions are needed to manage the pain.
What equipment should the nurse use to most accurately measure a 2ml dose of a viscous liquid solution to be given orally?
- A. 3 mL syringe and a sterile needle.
- B. One ounce medicine cup.
- C. 3 mL syringe.
- D. Tuberculin syringe.
Correct Answer: C
Rationale: A 3 mL syringe is precise and suitable for measuring a 2 mL dose of a viscous liquid. Syringes provide clear markings, ensuring accurate measurement of small volumes. Additionally, the absence of a needle makes it appropriate for oral administration.