The charge nurse notices another nurse on the floor reading the chart of a client who is not under her care. When confronted, the nurse says, 'This client is my neighbor, and I'm just concerned about him.' Which is the correct response by the charge nurse?
- A. As long as you don't share any information, it's okay.'
- B. Why don't you just let his nurse update you on his status?'
- C. You should not be reading the client's chart if you are not involved in his care.'
- D. Go with the doctor when he rounds on this client so you will be able to answer the family's questions.'
Correct Answer: C
Rationale: Accessing a chart without a care-related purpose violates HIPAA and patient privacy, regardless of personal relationships.
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A client is admitted with suspected Hodgkin's lymphoma. The diagnosis is confirmed by the:
- A. Overproliferation of immature white cells
- B. Presence of Reed-Sternberg cells
- C. Increased incidence of microcytosis
- D. Reduction in the number of platelets
Correct Answer: B
Rationale: Hodgkin's lymphoma is diagnosed by the presence of Reed-Sternberg cells, large abnormal cells found in lymph node biopsies.
A client is admitted with a blood alcohol level of 180 mg/dL. The nurse recognizes that the alcohol in the client's system should be fully metabolized within:
- A. 3 hours
- B. 5 hours
- C. 7 hours
- D. 9 hours
Correct Answer: D
Rationale: A blood alcohol level of 180 mg/dL (0.18%) typically takes about 9 hours to metabolize, assuming a metabolism rate of 0.02% per hour.
The nurse is caring for a client with a history of schizophrenia, alcohol abuse, bipolar disorder, and noncompliance with treatment and medications. The client has also been arrested in the past for violent behavior. Which action by the nurse is the most important when caring for a potentially violent client?
- A. treat the client with courtesy and respect
- B. always maintain an open pathway to the door
- C. be sure the client swallows his pills and does not 'cheek' them
- D. ask permission from the client before drawing blood or performing other invasive procedures
Correct Answer: B
Rationale: Maintaining an open pathway to the door ensures the nurse’s safety if the client becomes violent, prioritizing personal safety.
A 4-year-old male is admitted to the unit with nephrotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:
- A. Apply ice to the scrotum
- B. Elevate the scrotum on a small pillow
- C. Apply heat to the abdominal area
- D. Administer an analgesic
Correct Answer: B
Rationale: Elevating the scrotum reduces edema by promoting fluid drainage, decreasing discomfort.
A 19-year-old male has been experiencing vomiting and diarrhea for 3 days due to food poisoning. The nurse expects a urine specific gravity of
- A. 0.850.
- B. 1.005.
- C. 1.020.
- D. 1.041.
Correct Answer: D
Rationale: Dehydration from vomiting and diarrhea increases urine specific gravity (normal 1.005-1.030). 1.041 indicates concentrated urine due to fluid loss.
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