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The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who is
- A. receiving albuterol via a nebulizer and reports feeling 'nervous'.
- B. awaiting a home healthcare referral following total hip arthroplasty.
- C. six hours post-op from a hysterectomy and is reporting nausea.
- D. reporting that their arm is 'sleeping' after having a cast for a fracture applied three hours ago.
Correct Answer: D
Rationale: Numbness ('sleeping' arm) post-cast application (D) suggests possible compartment syndrome or nerve compression, a surgical emergency requiring immediate follow-up. Nervousness from albuterol (A) is expected, home health referral (B) is non-urgent, and post-op nausea (C) is common but less critical.
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The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? A client with
- A. chronic anemia requiring epoetin injections.
- B. a resolving pneumothorax with a chest tube.
- C. a tracheostomy requiring intermittent suctioning.
- D. septic shock requiring multiple interventions intravenous (IV) and vasopressors.
Correct Answer: D
Rationale: Septic shock requiring IV vasopressors (D) is a critical condition needing RN expertise for titration and monitoring. Anemia (A), resolving pneumothorax (B), and tracheostomy suctioning (C, C)) are more stable or routine, suitable for LPN care under supervision.
The nurse is conducting a staff in-service on client privacy. Which of the following actions would the nurse recognize as violations of client confidentiality? Select all that apply.
- A. Accessing a co-worker's address in their medical record to surprise them with a birthday gift.
- B. Reviewing a client's prescriptions with a student nurse who is assigned to the client.
- C. Looking up the medical information of a friend from a previous stay, even with their permission.
- D. Viewing a friend's medical record because you are listed as their power of attorney.
- E. Walking away from a computer terminal without securing it, even if the monitor is turned off.
Correct Answer: A, C, E
Rationale: Accessing a co-worker’s record for personal reasons (A), viewing a friend’s past record without current need (C), and leaving an unsecured computer (E) violate HIPAA confidentiality rules. Reviewing prescriptions with an assigned student (B) is educational, and viewing as power of attorney (D) may be authorized.
The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who
- A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C).
- B. has an indwelling urinary catheter and reports burning at the insertion site.
- C. has scant blood in their newly established ostomy pouch.
- D. has friends writing words on their fiberglass cast with different colored markers.
Correct Answer: A
Rationale: A fever of 101°F in Hirschsprung’s disease (A) suggests possible enterocolitis, a life-threatening complication requiring immediate follow-up. Catheter burning (B), scant ostomy blood (C), and cast writing (D) are less urgent, as they are expected or non-threatening.
According to the National Council of State Boards of Nursing, which of the following are included in the five rights of delegation? Select all that apply.
- A. Right task
- B. Right circumstance
- C. Right person
- D. Right direction and communication
Correct Answer: A, B, C, D
Rationale: The five rights of delegation per NCSBN include right task (A), circumstance (B), person (C), direction/communication (D), and supervision (not listed). All listed options are correct.
The nurse is planning a staff development conference about the care of transgender clients. Which of the following information should the nurse include? Select all that apply.
- A. At the start of the interview, inquire about the client's preferred pronoun.'
- B. Utilize binary gender terms on healthcare documentation.'
- C. Transgender individuals feel a variance between gender and natal sex.'
- D. Clients who are transgender may be reluctant to seek healthcare.'
- E. Inquire about any current or future plans for hormone therapy.'
Correct Answer: A, C, D, E
Rationale: Inquiring about pronouns (A), recognizing gender variance (C), acknowledging healthcare reluctance (D), and discussing hormone therapy (E) are inclusive and relevant. Binary gender terms (B) are inappropriate, as they exclude non-binary identities.