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The expectant mother asks the nurse, "With all the babies in the nursery, how will I know that the nurse is bringing rue my baby?" What is the nurse's best response?
- A. "The baby has a plastic bracelet with permanent locks that must be cut for removal."
- B. "If taken from the unit, your baby's security band will set off an alarm and lock exits."
- C. "Your identification number and full name are printed on your baby's identification band."
- D. "An identification band is applied to your infant, and footprints are taken and kept on record."
Correct Answer: C
Rationale: Matching identification numbers and the mother's full name on the infant's band ensures accurate identification, which is the primary method.
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Which of these instructions should the nurse include when preparing a client for a radioactive iodine (I-131) uptake test and treatment for hyperthyroidism?
- A. Avoid taking aspirin for 3 days prior to the test.'
- B. You may eat a light breakfast on the morning of the test.'
- C. Expect to stay in the hospital for 24 hours after treatment.'
- D. In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation.'
Correct Answer: A
Rationale: In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation. The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours.
A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is
- A. I must document and report any information.
- B. I can't make such a promise.
- C. That depends on what you tell me.
- D. I must report everything to the treatment team.
Correct Answer: B
Rationale: Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.
The UAP is caring for the client who has been placed in bilateral wrist restraints. Which direction should the nurse give to the UAP?
- A. "The wrist restraint must remain on at all times but can be loosened if needed."
- B. "The client attempted to harm staff; only enter the room with another person."
- C. "Ask the client about the need for toileting and offer liquids every two hours."
- D. "Assess the client's skin condition and provide hand exercises every two hours."
Correct Answer: C
Rationale: The UAP should check toileting and hydration needs every two hours, as the restrained client cannot manage these independently. Skin assessment (D) is beyond UAP scope.
Signs of internal bleeding include all of the following except:
- A. painful or swollen extremities.
- B. a tender, rigid abdomen.
- C. vomiting bile.
- D. bruising.
Correct Answer: C
Rationale: Vomiting bile is usually not a sign of internal bleeding. Painful or swollen extremities, a tender, rigid abdomen, and bruising are indicative of internal bleeding.
A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?
- A. I am sorry. Referral information can only be provided by the client's providers
- B. I can never give any information out by telephone. How do I know who you are?
- C. Since this is a referral, I can give you this information
- D. I need to get the client's written consent before I release any information to you
Correct Answer: D
Rationale: In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared.